Every finding on record at Rest Haven Nursing Home Inc

Based on observation, staff interview, review of the United States Department of Administration (USDA) website, and facility policy review, the facility failed to maintain a clean and sanitary kitchen and failed to ensure unpasteurized eggs were thoroughly cooked prior to serving. This had the potential to affect all residents in the facility except Resident #9 who does not eat food from the kitchen. The census was 67. Findings include:Observation on 08/04/25 at 9:06 A.M. of the kitchen walk-in refrigerator revealed a box containing unpasteurized eggs.Interview on 08/04/25 at 9:07 A.M. with Dietary Manager (DM) #162 revealed she usually ordered pasteurized eggs. She explained the company was out at the time she was making her order and purchased the unpasteurized instead. DM #162 acknowledged individual eggs were used for residents who requested sunny side up eggs, and they were served to two (#26 and #27) residents that morning for breakfast. DM #162 stated she was not aware pasteurized eggs were required for eggs which were not thoroughly cooked.Further observation of the kitchen on 08/04/25 at 9:12 A.M. revealed three ceiling vents in the serving area of the kitchen. Two of the three vents were approximately three feet in front of the serving tray line. The vents were observed to have dark, round particles scattered approximately eight to 12 inches surrounding the vents. Interview on 08/04/25 at 9:12 A.M. with DM #162 stated the ceiling had what appeared to be dust surrounding the ceiling vents. She acknowledged the area around the serving line should be free of possible contamination.Review of the United States Department of Administration (USDA) website, at https://www.fsis.usda.gov/food-safety/safe-food-handling-and-preparation/eggs/egg-products-and-food-safety, revealed the USDA does not recommend eating raw shell eggs that are not cooked or are undercooked due to the possibility that Salmonella may be present.Review of the facility policy titled, Food Preparation and Service, revised 11/22, revealed identification of potential hazards in food preparation process and adhering to critical control points can reduce the risk of food contamination. Also documented was only pasteurized egg shells are cooked and served when a residents requested undercooked, soft-served or sunny side up eggs.

Based on review of water management policies, staff interview, and review of electronic mail documents, the facility failed to ensure the water management plan for Legionella prevention was fully implemented. This had the potential to affect all 67 residents in the facility. The facility census was 67. Findings Include: Review of facility policy titled, The Water Management Plan, dated July 2017, revealed the water management program was based on the Centers for Disease Control and Prevention and the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) documentation. Further review revealed the water management program should include a detailed description and diagram of the water system, a system to monitor the control limits and effectiveness, and documentation of the program.Review of the undated facility Legionella prevention policy revealed water heater water temperatures will be gathered weekly and documented to ensure minimum water temperature of 140 degrees (Fahrenheit) and the ice machines will be cleaned quarterly and documented. Additional review revealed there was no description or diagram of the facility water system.Interview the Director of Maintenance (DOM) #101 on 08/06/25 at 12:10 P.M. revealed the facility was not documenting the water temperature for the water heaters. Further interview revealed the ice machine internals are cleaned by a contracted company twice a year.Review of an electronic mail (email) document from a contracted company dated 08/06/25 confirmed the kitchen ice machine was scheduled to receive maintenance twice a year.Interview with DOM #101 and the Director of Nursing (DON) on 08/07/25 at 2:40 P.M. confirmed there was no written detailed description of the water supply and no diagram was available at the facility. Further interview confirmed the ice machine was cleaned twice a year, but the facility policy indicated it would be cleaned quarterly.Interview with the DOM #101 at 4:10 P.M. on 08/07/25 revealed the facility was able to get a copy of the facility water flow diagram from corporate.

Based on medical record review, staff interviews, and policy review, the facility failed to complete a Minimum Data Set (MDS) assessment accurately for one (#70) of one residents reviewed for MDS assessment accuracy. The facility census was 67.Findings include:Review of the medical record for Resident #70 revealed an admission date of 04/09/25 with diagnoses of cerebral infarction, cognitive communication deficit, aphasia following cerebral infarction, type II diabetes mellitus without complications, and urinary tract infection.Review of the MDS assessment dated [DATE] revealed Resident #70 was cognitively able to make daily decisions with modified independent, and the resident did not have a urinary tract infection in the last 30 days.Review of the hospital Discharge summary dated [DATE] revealed Resident #70 was started on intravenous antibiotic medication for a urinary tract infection.Review of the progress note dated 04/15/25 at 6:16 P.M. revealed Resident #70 was readmitted to the facility with a diagnosis of urinary tract infection with an order for an antibiotic medication.Review of the Discharge Return Anticipated MDS assessment dated [DATE] revealed Resident #70 was cognitively able to make daily decisions with modified independent, and the resident did not have a urinary tract infection in the last 30 days.Review of the hospital Discharge summary dated [DATE] revealed Resident #70 was started on oral antibiotics for a urinary tract infection.Review of the progress note dated 05/01/25 at 4:52 P.M. revealed Resident #70 continued on the antibiotic for a urinary tract infection.Review of the Discharge Return Not Anticipated MDS assessment dated [DATE] revealed Resident #70 was cognitively able to make daily decisions with modified independent, and the resident did not have a urinary tract infection in the last 30 days.Interview on 08/07/25 at 8:31 A.M. with MDS Coordinator #147 confirmed Resident #70 did have a urinary tract infection on admission on [DATE], and had a diagnosis of a urinary tract infection on her hospital readmission dates of 04/15/25 and 04/26.25. MDS Coordinator #147 confirmed the MDS assessments dated 04/13/25, 04/24/25, and 05/06/25 did not list Resident #70 as having a urinary tract infection in the last 30 days.Review of the Resident Assessment policy, dated October 2023, revealed information in the MDS assessments will consistently reflect information in the progress notes, plans of care, and resident observations and interviews.

Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure interventions and continued assessments were implemented for a skin condition. This affected one (#14) of three residents reviewed for skin conditions. The facility census was 67.Findings include: Review of medical record for Resident #14 revealed an admission date of 06/26/23. The resident was admitted with diagnoses including Alzheimer's disease, anxiety, depression, and chronic obstructive pulmonary disease (COPD). Review of the quarterly MDS assessment dated [DATE] revealed Resident #14 had impaired cognition, required set up assistance for eating, and supervision for bed mobility, transfers, and toileting hygiene. Review of Resident #14's care plan included a potential risk for impairment of skin integrity with interventions to provide treatments per physician orders. Review of Resident #14's physician orders revealed an order for weekly skin assessments with a start date of 04/20/25. Observation of Resident #14 on 08/04/25 at 10:34 A.M. revealed a reddened area on the resident's chin approximately 0.6 centimeters (cm) long by (x) 0.3 cm wide x 0.0 cm deep. Review Resident #14's progress note dated 07/27/25 revealed redness was observed on the resident's chin, and the resident stated the area felt bumpy with no complaints of pain or itchiness. The physician was updated. Review of Resident #14's 07/27/25 skin assessment documented redness to the chin with no measurements documented. The intervention was cream. Interview on 08/06/25 at 4:02 P.M. with Licensed Practical Nurse (LPN) #134 revealed she had noticed the red area on Resident #14's chin; however, there were no orders for a treatment. LPN #134 proceeded to show a secured text message Physician #1 was send, to confirm the physician was notified, but there was no return text documented. LPN #134 acknowledged there were no other skin assessments of Resident #14's chin since the original assessment on 07/27/25. Interview on 08/07/25 at 3:33 P.M. with the Director of Nursing (DON) acknowledged there was no additional documentation of the redness of Resident #14's chin after 07/27/25 and no treatment was in place for the skin condition. Review of Resident #14's physician orders revealed an order for house lotion to the face due to dryness as the resident tolerates and to monitor the red area on her chin for signs and symptoms of infection until healed with a start date of 08/08/25. Review of the facility's undated policy titled, Pressure Prevention and Managing Skin Integrity, revealed findings would be documented and skin interventions would be implemented and documented on the appropriate form.

Based on medical record review and staff interview, the facility failed to ensure an investigation was completed following a resident fall. This affected one (#10) of three reviewed for falls. The facility census was 67. Findings include:Review of the medical record for Resident #10 revealed an admission date of 06/17/22 with diagnoses including age related osteoporosis without current pathological fracture, type II diabetes mellitus without complications, and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the discharge return anticipated Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively impaired and had one fall with major injury since admission. Review of the care plan dated 06/20/22 revealed Resident #10 had a potential for or was at risk for injuries/falls related to diagnoses and history of falls with interventions of anticipate needs as able, encourage non-skid footwear at all times, monitor safety/preventative devices for application, and instruct on use of adaptive equipment as needed. Review of the progress note dated 01/18/24 at 10:36 P.M. revealed staff was assisting Resident #10 putting on a new brief when the resident lost her balance and fell. Review of the Fall During Staff Assist report, dated 01/18/24 revealed Resident #10 was being assisted with putting on a new brief when the resident lost her balance and fell over. The resident was standing up in front of the toilet with the walker in front of her when the fall occurred. Interview on 08/07/25 at 2:52 P.M. with the Director of Nursing (DON) confirmed Resident #10 did fall on 01/18/24 when a staff member was providing assistance with applying a brief to the resident. The DON also revealed a fall investigation was not fully completed with witness statements and documentation of who was present during the fall and how it happened. The DON confirmed the facility did not have a policy on completing investigations.

Based on observation, medical record review, resident and staff interview, and review of facility policies, the facility failed to ensure residents received meals prior to scheduled appointments and failed to receive nutritional supplements as ordered. This affected two (#8 and #40) of eight residents reviewed for nutritional services. The census was 67. Findings include: 1. Record review for Resident #8 revealed the resident was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #8 include end stage renal disease and chronic obstructive pulmonary disease. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had mildly impaired cognition and was receiving dialysis treatments. Review of Resident #8's care plans dated 05/19/25 revealed a focus for altered nutrition relating to dialysis and other co-morbidities. A goal for the focus include the facility will provide nourishing meals daily to meet the needs of the resident. An intervention included to provide meals per diet order. Observation on 08/05/25 at 8:50 A.M. of Resident #8's room revealed the resident was not in the room and the breakfast tray containing a fried egg, breakfast sandwich, glass of orange juice, and a cup of coffee was sitting on the resident's night stand. The food appeared to be untouched and the silverware was still wrapped in a napkin. Interview on 08/05/25 at 9:08 A.M. with Licensed Practical Nurse (LPN) #107 revealed Resident #8 goes out of the facility for dialysis on Tuesday, Thursdays, and Saturdays. Per LPN #107, the resident leaves around 6:30 A.M. before breakfast was served at 8:00 A.M. LPN #107 stated she was unaware of any breakfast provided to Resident #8 before she goes to dialysis and stated she was unaware if the resident had refused her breakfast meal in the mornings before dialysis. Interview on 08/05/25 at 10:11 A.M. with Certified Nurse Aide (CNA) #117 revealed the aide arrives at the facility around 6:30 A.M. CNA #117 stated usually on the days Resident #8 goes to dialysis she was not in her room when CNA #117 arrives for her shift. CNA #117 stated the breakfast trays are served between 7:30 A.M. and 8:00 A.M. after Resident #8 leaves for her appointments. CNA #117 stated if the resident requests any breakfast the staff can provide her a snack upon request. CNA #117 stated she was unaware of any time Resident #8 has refused her meals. CNA #117 stated when the resident returns if lunch meal has been served the resident's lunch tray was placed in the refrigerator on the unit and given to her when she requests her meal. Interview on 08/05/25 at 2:12 P.M. with Resident #8 revealed the resident stated she had not been offered any food for breakfast on days she has to leave at 6:30 A.M. for dialysis. Resident #8 stated she had not refused her meals but stated she will wait until she returns to the facility to eat her lunch. Resident #8 stated no staff have offered her a supplement for her trips to dialysis. Resident #8 stated she was unaware she could request supplements or snacks for her appointments. 2. Review of the medical record for Resident #40 revealed an admission date of 03/24/22 with diagnoses of major depressive disorder, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the quarterly MDS assessment dated [DATE] revealed Resident #40 was cognitively impaired and had not lost five (5) percent (%) or more in the last month or had a loss of 10% or more in last six (6) months. Review of Resident #40's weight logs revealed a weight of 211.0 pounds on 05/14/25 and a weight of 200.8 pounds on 05/28/25. Review of the Doctor Notification of Weight Change form dated 06/18/25 revealed the physician was notified of Resident #40's 27 pound weight loss over a 6 month period. Review of the progress note dated 06/19/25 at 9:52 A.M. revealed a new order was received for Resident #40 to received Med Pass 120 milliliters (mL) two times daily due to a 11.8% weight loss. Review of Resident #40's physician orders revealed and order dated 07/08/25 for 60 mL of Med Pass daily. Interview on 08/06/25 at 10:18 A.M. with Registered Dietician #221 confirmed on 06/20/25 she had already recommended Resident #40 to start on Med Pass 120 mL twice daily due to weight loss and that order was not initiated. Interview on 08/06/25 at 10:27 A.M. with LPN #196 confirmed she received a verbal order for Resident #40 on 06/19/25 for Med Pass 120 mL twice daily due to an 11.8% weight loss. Interview also confirmed the order was not written and not implemented. Review of the principles and standards of nutritional care policy, dated September 2018, revealed residents' nutritional care will be consistent with current standards of clinical practice for the elderly or facility population and comply with regulatory standards as applicable. Review of the medication and treatment orders policy, dated July 2016, revealed orders for medications and treatments will be consistent with principles of safe and effective order writing. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date and the time of the order.

Based on medical record review, staff interview, review of the facility's policy, the facility failed to ensure residents were not unnecessarily prescribed antibiotic medications. This affected one (#19) resident of five residents reviewed for unnecessary medications. The census was 67. Findings include:Record review for Resident #19 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #19 include hemiplegia, weakness, dysphagia, chronic obstructive pulmonary disease, and heart disease. Further review of the resident's diagnoses records revealed no active diagnosis for bronchiectasis (a chronic lung condition where the airways (bronchial tubes) become widened and damaged, making it difficult to clear mucus). Review of Resident #19's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and received antibiotic medications. Review of Resident #19's physician orders dated 04/01/24, and revised on 07/16/24, revealed the resident was to receive Levaquin (antibiotic) 750 milligrams (mg) orally daily on the first of the month for five (5) days each month for bronchiectasis. Per the order the medication had no stop date. Review of Resident #19's care plans dated 12/06/23 to 10/24/25 revealed no focus for any type of infection risk in the care plans. Review of Resident #19's complete blood count (CBC) laboratory test dated 04/01/25 revealed no evidence in the test results indicating any infection process. [NAME] blood cells were within normal range and no abnormal results were noted. Review of the pharmacist's monthly medication reviews dating from July 2024 to July 2025 revealed each month the pharmacist reviewed Resident #19's medications and made no recommendations regarding the antibiotic. Interview on 08/07/25 at 11:30 A.M. with the Director of Nursing, (DON) revealed Resident #19 was receiving the Levaquin oral antibiotic for prophylactic reasons to prevent bronchiectasis. Per the DON, the staff have consulted with the prescribing physician and explained the resident had no signs of infection; however, the physician continued to prescribe the antibiotic to the resident. The DON verified the Levaquin was an unnecessary medication in terms of the resident having no signs or symptoms of a respiratory infection and stated the resident continued to receive the oral antibiotic for 5 days a month per the physician's order. Review of the facility policy titled, Medication Therapy, dated 04/2007, revealed the facility will ensure all residents' medication regimen shall only include medications necessary to treat existing conditions.

Based on observation, record review, and staff interview, the facility failed to provide effective pest control to prevent gnats /fruit flies throughout the facility. This affected one resident (#43) out of the 13 residents sampled but had the potential to affect all residents at the facility. The facility census was 50. Findings include: Record review for Resident #43 revealed an admitted [DATE]. Her diagnosis included Coronavirus (COVID-19), osteoarthritis, dementia, essential primary hypertension, hypothyroidism, and hyperlipidemia. Review of the admission minimum data set (MDS) assessment revealed resident had impaired cognition. Further review of the MDS assessment, revealed Resident #43 required extensive assistance from staff with dressing, bed mobility, personal hygiene, and transfers. Interview on 12/12/22 at 3:37 P.M. with Resident #43's representative revealed she was sitting in the common dining room with Resident #43 and swatted at gnats/fruit flies. Resident's representative stated she asked the staff several times regarding gnats/fruit flies and why the facility had not treated the issue. Resident's representative stated she was told the gnats/fruit flies were in the building after pumpkins were brought into the facility. Interview on 12/14/22 at 3:54 P.M. with Licensed Practical Nurse (LPN) #140 confirmed the observation of gnats/fruit flies flying around the sink in the residents dining room. Interview on 12/14/22 at 04:19 P.M. with the Maintenance Supervisor (MS) #124 confirmed the facility had an issue with gnats/fruit flies for about a month. MS #124 stated he planned to tell the exterminator when he was at the facility, however, he did not catch him in time to discuss the concerns. MS #124 thought the gnats/fruit flies concern may be an issue with the drains at the facility. Observation on 12/15/22 at 8:55 A.M. during an interview with Social Service Director (SSD) #100 regarding resident accounts revealed she was sitting at her desk swatting her hands in the air at gnats/fruit flies. SSD #100 verified she was trying to get the gnats/fruit flies in the office. Review of the facility policy titled, Pest Control, dated 2001, this facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Review of the Service Agreement with Buckeye Exterminating dated 12/08/22 revealed common exclusions that could be included at an additional cost included, fly& gnat control.

Based on medical record review, resident interview, staff interview, and review of facility policy, the facility failed to have fall interventions in place. This affected two residents (#7 and #37) of four reviewed for accidents. The census was 50. Findings include: 1. Review of Resident #7's medical record revealed an admitted [DATE]. Diagnoses list included metabolic encephalopathy, dysphagia, hypertension, osteoarthritis, atrial fibrillation, and rheumatoid arthritis. Review of a recent minimum data set (MDS) assessment for Resident #7, revealed resident was assessed as being moderately cognitively impaired, required supervision with bed mobility, extensive assistance with transfers, and had falls prior to admission. Review of a care plan initiated on 10/26/22, revealed Resident #7 had potential for and was at risk for injuries/falls. Interventions included monitor safety/preventative devices for applications, instruct on use of adaptive equipment as needed and a perimeter mattress to help define bed boundaries. Review of progress notes dated 11/16/22 at 8:01 P.M., revealed Resident #7 was lying on the floor on her right side near bed and vital signs were taken. Resident #7 complained of right arm pain and had a hematoma to her right forehead. Review of progress notes dated 11/16/22 at 8:20 P.M., revealed Resident #7 was sent to a local emergency room for evaluation. Review of an interdisciplinary team (IDT) notes dated 11/17/22 at 10:18 A.M., revealed Resident #7 fell from her bed on 11/16/22 at 7:45 P.M. Notes indicated Resident #7 was in bed and rolled out. IDT notes indicated a new intervention for a scoop/perimeter mattress was added and the care plan was updated. During an interview on 12/13/22 at 7:31 A.M. with Resident #7 indicated she fell out of bed and busted her face. Observation 12/14/22 at 2:25 P.M. with the Director of Nursing (DON), revealed Resident #7's bed did not have a scoop/perimeter mattress. Interview with DON at the same time indicated Resident #7's bed should have had a scoop/perimeter mattress in place as a fall intervention and verified Resident #7's bed did not have scoop/perimeter mattress per her care plan. 43062 2. Review of Resident #37's medical record revealed Resident was admitted to the facility on [DATE]. Diagnoses included Coronavirus (COVID-19), Alzheimer's disease, dysphagia, psychosis, anxiety disorder and urinary tract infection. Review of the quarterly MDS assessment for Resident #37, dated 09/06/22, revealed resident had severely impaired cognition. Further review of the MDS assessment revealed Resident # 37 required extensive assistance from staff with bed mobility, transfers, dressing, eating and personal hygiene. Review of the progress note for Resident #37 dated 07/13/22 revealed resident had a fall from the bed, and the facility identified the need for a parameter mattress to define bed boundaries. Progress note dated 09/02/22, revealed Resident #37 was found sitting on the floor on the side of the bed and the facility identified the need to pad Resident #37's bed frame for injury prevention. Progress note dated 10/21/22, revealed Resident #37 was found on the floor in her room next to her bed and the facility identified the need to have a fall mat placed on the right side of her bed as an intervention. Review of physician orders dated 07/14/22 for Resident #37, revealed resident was ordered a perimeter mattress to define bed boundaries for fall preventions. Physician orders dated 09/06/22, revealed resident was ordered a padded lateral bed frame for injury preventions. Physician orders dated 10/28/22, revealed resident was ordered a fall mat to floor on right side of bed every shift for fall interventions for injury prevention. Observation on 12/14/22 at 10:06 A.M. with Occupational Therapist (OT) # 162 revealed Resident #37 was lying in bed with no fall mat on the floor at the bed side as ordered. Interview at same time with OT #162 indicated Resident #37 should have a fall mat on the floor and next to bed when resident was in bed due to fall risk. OT #162 verified no fall mat was in place for Resident #37. Observation on 12/14/22 at 1:23 P.M. with the Director of Nursing (DON) revealed Resident #37 did not have a parameter mattress on her bed and the bed frame did not have padding on it as ordered. Interview with DON at same time, revealed Resident #37 was recently moved from another room and the staff did not mot the correct bed with resident. DON verified resident's bed should have a parameter mattress and a padded bed frame for fall interventions. Review of the facility policy titled, Falls and Fall Risk Managing, undated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure staff followed standard precautions and transmission-based precautions (TBP) when caring for residents. This affected one resident (#1) of the five residents observed in TBP but had the potential to affect all the residents of the facility. The census was 50. Findings include: 1. Review of Resident #1's medical record revealed an admitted [DATE]. Diagnoses listed include multiple sclerosis, tracheostomy/ventilator dependent, hypertension, major depressive disorder, and seizures. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was assessed as being cognitively intact. Review of sputum culture results dated 08/21/22 revealed Resident #1 was positive for the drug resistant organism consistent with extended spectrum beta-lactamase (ESBL). Further medical record review revealed an order dated 08/23/22 for Resident #1 to be in contact precautions. Observation on 12/12/22 at 10:45 A.M. revealed state tested nursing assistant (STNA) #234 in Resident #1's room assisting her at bedside. STNA #234 took a book form Resident #1, handed Resident #1 her bed controller, touched, and arranged items on her bedside table. STNA #234 leaned on Resident #1's bedside table and used it to write. STNA #234 was not wearing a gown or gloves. Signs were posted on the entrance to Resident #1's room identifying resident was in contact precautions. A bin containing personal protective equipment, such as gloves and gowns was located at the entrance of Resident's doorway. Observation on 12/12/22 at 10:49 A.M. revealed STNA #234 exited Resident #1's room without washing or sanitizing her hands. Interview with STNA #234 at same time, confirmed Resident #1 was in contact precautions. STNA #234 confirmed she did not wear a gown and gloves while assisting Resident #1. During an interview on 12/12/22 at 11:15 A.M. with Registered Nurse (RN) #206, she confirmed Resident #1 was on extended contact precautions due to being positive for a drug resistant organism. RN #206 confirmed STNA #234 should have been wearing a gown and gloves while caring for Resident #1 and STNA #234 should have completed hand hygiene before exiting Resident #1's room. Review of the facility's undated policy titled Isolation-Categories of Transmission-Based Precautions revealed staff and visitors will wear gloves (clean, non-sterile) when entering the room. Gloves would be removed, and hand hygiene performed before leaving the room. Staff and visitors would wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. Review of the CDC website titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) (https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html), updated 07/12/22, revealed Added additional rationale for the use of Enhanced Barrier Precautions (EBP) in nursing homes, including the high prevalence of multidrug-resistant organism (MDRO) colonization among residents in this setting, expanded residents for whom EBP applies to include any resident with an indwelling medical device or wound (regardless of MDRO colonization or infection status), and CDC clarified that, in the majority of situations, EBP are to be continued for the duration of a resident's admission. EBP's are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. Standard Precautions, which are a group of infection prevention practices, continue to apply to the care of all residents, regardless of suspected or confirmed infection or colonization status. EBP expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and wound care

Based on record review and staff interview, the facility failed to ensure staff assessed a resident for the effectiveness/ineffective of non-pharmacological pain interventions. Additionally, the facility failed to ensure complaints of pain were addressed in a timely manner, including physician notification of pain. This affected one (#1) of three residents reviewed for pain management. The facility census was 50. Findings include: Review of the medical record for Resident #1 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Tylenol order was discontinued on 10/01/21 and the [MEDICATION(S)] order was updated on 10/02/21 to [MEDICATION(S)] patch four percent. Review of an admission pain assessment, dated 10/01/21, revealed Resident #1 was assessed to have no pain. Review of a care plan, dated 10/04/21, revealed Resident #1 had the potential for pain and/or joint discomfort related to debility and joint stiffness. The resident's pain was to remain controlled as evidence by own comfort level daily for 30 days. Interventions include to determine source and severity of pain and measures that relieve it, administer appropriate medication, document effectiveness, or ineffectiveness, and notify the physician if pain was uncontrolled. Review of an admission Minimum Data Set (MDS) assessment, dated 10/08/21, revealed Resident #1 had intact cognition. Resident #1 experienced pain or hurting at any time in the last five days and the resident frequently experienced pain or hurting in the last five days. Over the last five days, pain had made it hard for the resident to sleep at night and the worst pain was an eight, on a zero to ten pain scale (zero being no pain and ten as the worst pain you can imagine). Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. The pain was rated as a four. On 10/06/21 at 6:30 P.M., Resident #1 complained of pain and rated the pain a four. On 10/07/21 at 6:30 A.M., Resident #1 reported pain and rated the pain a four. On 10/08/21 at 6:30 A.M., Resident #1 reported the pain was a five and on 10/09/21, the pain was five, and on 10/10/21 pain was a five. Review of the medical record for Resident #1 revealed no evidence of physician notification for the new pain that was reported by Resident #1 on 10/02/21 at 6:30 A.M. There was no evidence of staff determining the source and severity of pain, measures that relieve the pain, reevaluation of the pain or, effectiveness/ineffectiveness of pain interventions for the pain that was assessed on 10/02/21 at 6:30 A.M., 10/06/21 at 6:30 P.M., 10/07/21 at 6:30 A.M., 10/08/21 at 6:30 A.M., 10/09/21 at 6:30 A.M., and 10/10/21 at 6:30 A.M. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .M., revealed Resident #1 had an acute visit for complaints of pain. Resident #1 described the pain as located in the right stump, throbbing, tingling, and numbness. Documentation revealed Resident #1 had multiple medical problems including [CONDITION(S)], new onset [CONDITION(S)], [CONDITION(S)], and multiple medication allergy/intolerance. The incision line to the right stump was documented as clean, dry, intact, and appeared well healed. The plan was to try [MEDICATION(S)] (treats nerve pain) and start at a low dose and titrate as needed. Review of a progress note, dated 10/08/21 at 4:21 P.M., revealed Resident #1 received a new order for [MEDICATION(S)] 100 mg by mouth daily at bedtime for three days. Then start [MEDICATION(S)] 100 mg by mouth twice a day. Interview on 11/10/21 at 12:15 P.M. with the Director of Nursing (DON) verified the medical record for Resident #1 contained no evidence of the effectiveness or ineffectiveness of non-pharmalogical interventions provided for Resident #1 during the month of 10/2021. The DON verified Resident #1's admission assessment reported no pain and new pain was reported by Resident #1 on 10/02/21 and 10/06/21. The DON verified the medical record contained no evidence of the primary care provider (PCP) being notified of Resident #1's reports of pain from 10/02/21 and 10/06/21 until 10/07/21. The DON verified the physician assessed Resident #1 on 10/07/21 and gave orders for [MEDICATION(S)]. The DON further verified Resident #1 reported pain on 10/07/21 at 6:30 A.M. and 10/08/21 at 6:30 A.M. The DON confirmed Resident #1's pain was not addressed timely. The DON further confirmed the PCP for Resident #1 was not notified of the resident's pain in a timely manner. This deficiency substantiates Complaint Number OH 176.

Based on record review and staff interview, the facility failed to ensure residents were free from significant medication errors. This affected one (#1) of three residents reviewed for medication administered. The census was 50. Findings include: Review of the medical record for Resident #1 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Another order was for [MEDICATION(S)] tablet 2.5 mg give one tablet by mouth two times a day for hypertension - hold for SBP less than 120. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The [MEDICATION(S)] [MEDICATION(S)] was administered on 10/06/21 at 8:00 P.M. - heart rate 51, 10/13/21 at 8:00 A.M. - heart rate 59, and on 10/20/21 at 8:00 P.M. - heart rate 56. Continued review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #1's SBP was below 120. The [MEDICATION(S)] was administered on 10/09/21 at 8:00 A.M. - SBP 117, 10/13/21 at 8:00 A.M. - SBP 110 and 8:00 P.M. SBP 118, 10/14/21 at 8:00 A.M. - SBP 118, and on 10/18/21 at 8:00 A.M. - SBP 112. Interview on 11/08/21 at 3:28 P.M. with the Director of Nursing (DON) verified Resident #1 was administered the medication [MEDICATION(S)] on 10/06/21 at 8:00 P.M. - heart rate 51, 10/13/21 at 8:00 A.M. - heart rate 59, and on 10/20/21 at 8:00 P.M. - heart rate 56, when the medication should have been held per the physician ordered heart rate parameters. The DON further verified the medication [MEDICATION(S)] was administered on 10/09/21 at 8:00 A.M. - SBP 117, 10/13/21 at 8:00 A.M. - SBP 110 and 8:00 P.M. - SBP 118, 10/14/21 at 8:00 A.M. - SBP 118, and on 10/18/21 at 8:00 A.M. - SBP 112, when the medication should have been held per the physician ordered SBP parameters. This deficiency substantiates Complaint Number OH 176.

Based on review of the facility's nursing schedules and list of agency staff, review of the facility's policy and staff interview, the facility failed to ensure a registered nurse was staffed for at least eight consecutive hours each day. This had the potential to all 43 residents who resided in the facility. Findings include: Review of the facility's nurse schedules, dated 10/21/20 through 12/08/20, revealed there was a Registered Nurse (RN) on duty each day through the week and every other weekend. The schedules revealed there was no RN coverage for Sunday 11/08/20, Saturday 12/05/20 and Sunday 12/06/20. Review of the facility's list of agency staffing revealed 18 State tested Nursing Assistants and three Licensed Practical Nurses were utilized by the facility. No RNs had been utilized. Interview with the Administrator on 12/09/20 at 11:15 A.M. revealed the facility had used agency staffing and any available department had assisted in taking care of the residents. He further stated he was aware the emergency staffing for COVID-19 did not prevent him from needing to staff with an RN for eight consecutive hours each day, but he could not find them. He verified he had not applied for an RN staff waiver. He stated there was no policy that dealt specifically with RN coverage and they went by the federal regulations. Subsequent interviews with the Administrator on 12/11/20 from 9:00 A.M. and 1:02 P.M. verified there was no RN on duty on 11/08/20, 12/05/20 and 12/06/20. Review of the facility's policy titled COVID-19 Staffing, dated 03/2020, revealed in emergencies, staffing was normally critical. The facility would use its staff in emergencies and may at times need alternate staffing arrangements in the event normal shift changes become a challenge to maintain. Additional staff could be obtained from sister facilities, staffing agencies and emergency nursing staffing programs, including the Medical Reserve Corp. Plans were in place for all departments to be able to assist in providing their available realms to meet resident needs. Review of the facility's policy titled Staffing, dated 10/2017, revealed the facility would provide sufficient numbers of staff with the skills and competency to provide care and services for all residents in accordance with resident care plans and facility assessment. Review of the facility's policy titled Department Duty Hours, Nursing Services, revised 08/2006, revealed nursing service was provided 24 hours a day, seven days a week. This deficiency substantiates Complaint Number OH 714.

Based on record review, review of the facility's policy and resident and staff interview, the facility failed to ensure residents received showers/bathing according to the facility's schedule. This affected four residents (#1, #2, #3 and #5) of four residents reviewed for bathing. The facility identified 38 residents who required assistance with bathing. The facility census was 44. Findings include: 1. Review of the medical record for Resident #1 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set 3.0 (MDS) assessment, dated 09/14/20, revealed the resident had no cognitive deficits or rejection of care. The resident required extensive assistance by staff with dressing and hygiene. Bathing was marked as did not occur. The resident was frequently incontinent of bowel and had moisture associated skin damage. Review of an undated shower schedule revealed Resident #1 was to receive showers on Tuesdays and Saturdays on the second shift. Review of the shower sheets and electronic Activity of Daily living charting, dated 10/01/20 through 12/09/20, revealed Resident #1 did not receive a shower on 10/10/20, 10/13/20, 10/17/20, 10/31/20, 11/10/20, 12/05/20 and 12/08/20. Interview with Resident #1 on 12/09/20 at 10:05 A.M. revealed she did not always get her showers/bed bath. She stated she thought her last one was several days ago. Interview with the Administrator on 12/11/20 at 2:51 P.M. verified there was no documentation of showers being provided to Resident #1 on 10/10/20, 10/13/20, 10/17/20, 10/31/20, 11/10/20, 12/05/20 and 12/08/20 2. Review of the medical record for Resident #2 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a quarterly MDS assessment, dated 11/24/20, revealed the resident had severely impaired cognition. The resident required extensive assistance with dressing. Bathing was marked as did not occur. The resident also had moisture associated skin damage (MASD). Review of an undated shower schedule revealed Resident #2 was to receive showers on Mondays and Fridays. Review of the shower sheets and electronic Activity of Daily living charting dated 10/01/20 through 12/09/20 revealed Resident #2 did not receive a shower on 10/05/20, 10/12/20, 10/23/20, 10/26/20, 10/30/20, 11/02/20, 11/06/20, 11/09/20, 11/13/20, 11/16/20, 11/23/20, 11/27/20 and 12/04/20. Interview with Resident #2 on 12/09/20 at 10:25 A.M. revealed he was not able to take a shower but did like the bed baths. He stated he had not received many lately and usually when he did get a bath, he had to ask for it. Interview with the Administrator on 12/11/20 at 3:14 P.M. verified there was no documentation of showers being provided to Resident #2 on 10/05/20, 10/12/20, 10/23/20, 10/26/20, 10/30/20, 11/02/20, 11/06/20, 11/09/20, 11/13/20, 11/16/20, 11/23/20, 11/27/20 and 12/04/20. 3. Review of the medical record for Resident #3 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a Medicare five-day MDS assessment, dated 11/15/20, revealed the resident had no cognitive deficits. Extensive assistance was required dressing, and personal hygiene. The resident also had MASD and was incontinent of bowel and bladder. Review of an undated shower schedule revealed Resident #3 was to receive showers on Tuesdays and Saturdays on the second shift. Review of the shower sheets and electronic Activity of Daily living charting dated 10/01/20 through 12/09/20 revealed Resident #3 did not receive a shower on 10/06/20, 11/14/20, 11/21/20, 11/28/20 and 12/08/20. Interview with Resident #3 on 12/09/20 at 10:30 A.M. revealed he had not received as many baths as he would want. Interview with the Administrator on 12/11/20 at 2:36 P.M. verified there was no documentation of showers being provided to Resident #3 on 10/06/20, 11/14/20, 11/21/20, 11/28/20 and 12/08/20. 4. Review of the medical record for Resident #5 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the admission MDS assessment, dated 10/27/20, revealed the resident had moderately impaired cognition. The resident required extensive assistance with dressing and hygiene. Bathing was marked as did not occur. Review of an undated shower schedule revealed Resident #5 was to receive showers on Wednesdays and Saturdays on the day shift. Review of the shower sheets and electronic Activity of Daily living charting dated 10/01/20 through 12/09/20 revealed Resident #5 did not receive a shower on 11/25/20, 11/28/20 and 12/05/20. Interview with Resident #5 on 12/09/20 at 12:20 P.M. revealed she did get some showers but had missed a few. Interview with the Administrator on 12/11/20 at 3:36 P.M. verified there was no documentation of showers being provided to Resident #5 on 11/25/20, 11/28/20 and 12/05/20. Interviews with State tested Nursing Assistants (STNA) #15, #40 and #45 on 12/09/20 between 10:55 A.M. and 12:10 P.M. revealed the shower sheets were to be filled out when it was a resident's shower day. They stated they were also to document it in the electronic record. If the shower was refused, it was to be documented and the nurse was to be notified. The STNAs stated there had been times showers were not able to be given but they tried to make it up the next day if they could. Interview with Licensed Practical Nurse #25 on 12/09/20 at 12:00 P.M. revealed STNAs were to fill out a shower sheet on each shower day of every resident. She stated the STNAs were supposed to check the resident's skin and if they saw anything abnormal they were to inform the nurse. The shower sheets were given to the nurse to be reviewed and signed off by the end of their shift. Review of an undated facility policy titled Personal Care- Bathing/showering Policy and Procedures revealed the residents were encouraged to remain independent as possible. The policy did not contain information the frequencies of showers, but referred staff to the resident's plan of care. This deficiency substantiates Complaint Number OH 714.

Based on medical record review, staff interview, review of facility policy, the facility failed to notify a resident's family/representatives for significant changes in condition. This affected one (#44) of three residents residents reviewed for notification of change. Facility census was 42. Findings include: Review of Resident #44's closed medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Resident #44 was assessed as being moderately cognitively impaired on a comprehensive Minimum Data Set ((MDS) dated [DATE]. Resident #44 was discharged from the facility on 08/03/20. Review of a health status note dated 07/21/20 at 10:16 A.M. revealed Resident #44 was noted with confusion and a decline in activities of daily living (ADL's). Review of a physician note dated 07/23/20 at 5:17 P.M. revealed Resident #44 was seen per nursing request due to increased confusion. Nursing reported Resident #44 was not herself and seemed less active. Review of physician orders [REDACTED]. Apply a heart-shaped bordered foam patch upside down. Use skin-prep (preventive skin treatment) to area around open area to secure foam patch. Treatment is to be completed every evening shift, every three days for open area on buttock. Another order dated 07/24/20 was to check border foam patch for placement every shift. Further review of Resident #44's closed medical record revealed no documentation of family/representative notification of increased confusion first noted on 07/21/20 and assessed for by physician on 07/23/20 or for the open area to buttock discovered on 07/24/20. Interview with the Director of Nursing (DON) on 09/22/20 at 1:00 P.M. confirmed there was no documentation of Resident #44's family/representative being notified of increased confusion on 07/21/20 and assessed for by physician on 07/23/20 or for the open area to buttock discovered on 07/24/20. Review of the facility's undated policy titled Change in a Resident's Status of Condition revealed unless otherwise instructed by the resident, a nurse will notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status. This deficiency substantiates Complaint Number OH 100.

Based on medical record review, staff interview, and review of facility policy, the facility failed to appropriately document and assess a resident's wound. This affected one (#44) of three residents sampled during the survey for skin breakdown. Facility census was 42. Findings include: Review of Resident #44's closed medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Resident #44 was assessed as being moderately cognitively impaired on a comprehensive Minimum Data Set ((MDS) dated [DATE]. Resident #44 was discharged from the facility on 08/03/20. Review of physician orders [REDACTED]. Apply a heart-shaped bordered foam patch upside down. Use skin-prep (preventive skin treatment) to area around open area to secure foam patch. Treatment is to be completed every evening shift, every three days for open area on buttock. Another order dated 07/24/20 was to check border foam patch for placement every shift. Review of treatment administration records (TAR's) form 07/24/20 through 08/03/20 revealed wound treatments were completed as ordered. Further review of Resident #44's closed record revealed there were no documentation of assessment of the buttock wound. No documentation of the buttock wound's size or condition was found. There was no etiology documented for Resident #44's wound. Review of weekly skin assessments dated 07/17/20 and 07/31/20 revealed there were no documentation of an open area to the buttock. Interview with the Director of Nursing (DON) on 09/22/20 at 1:00 P.M. confirmed there were no assessments of Resident #44's buttock wound in the medical record. The DON confirmed wounds should be assessed for size and condition on a regular basis, and that this should be documented in a resident's medical records. The DON confirmed that Resident #44's wound etiology was not documented in the medical record. Review of the facility's undated policy titled Pressure Ulcer Prevention and Managing Skin Integrity revealed skin Integrity and/or conditions affecting the resident's skin must be documented according to established procedures. The presence of skin breakdown/abnormal skin appearance, i.e. abrasion, blister, bruising - due to pressure, burn, denuded, [DIAGNOSES REDACTED], hematoma, laceration, rash, skin tear and wound, will be documented upon admission and regularly. Upon identification of a wound, a full wound assessment, including its location, and description of the tissue involved, will be completed. Interventions and progress toward outcome focused goals need regular documentation according to established procedures. This deficiency substantiates Complaint Number OH 100 and Complaint Number OH 712.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure a resident was free from unnecessary medication by not having justification for the administration of an anti-anxiety medication. This affected one (#50) of three residents reviewed for unnecessary medications. Facility census was 42. Findings include: Review of Resident #50's closed medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Resident #50 was assessed as having severe cognitive impairment in a comprehensive Minimum Data Set ((MDS) dated [DATE]. Resident #50 was discharged on [DATE]. Review of physician orders [REDACTED]. Review of progress notes dated 07/10/20 at 11:51 A.M. and 6:06 P.M. revealed Resident #50 has had increased anxiety and was started on [MEDICATION NAME] 5.0 mg twice a day. Further review of progress notes dated 06/07/20 through 07/09/20 revealed no documented instances of Resident #50 displaying anxiety or increased anxiety. Review of behavior assessments dated 07/02/20 through 07/17/20 revealed no documented anxiety for Resident #50. All assessments reviewed noted that no behaviors, including anxiety, were present on those days. Review of medication administration records (MAR's) dated 07/10/20 through 08/14/20 revealed [MEDICATION NAME] 5.0 mg was administered twice a day 07/11/20 through 08/13/20 at 8:00 A.M. and 8:00 P.M. [MEDICATION NAME] 5.0 mg was administered on 07/10/20 at 8:00 P.M. and on 08/14/20 at 8:00 P.M. Resident #50 was administered [MEDICATION NAME] 5.0 mg a total of 70 times. Interview with the Director of Nursing (DON) on 09/22/20 at 1:00 P.M. revealed there was no documentation of Resident #50 displaying anxiety or increased anxiety prior to 07/10/20. The DON confirmed there was no documented justification for Resident #50 being started on [MEDICATION NAME] on 07/10/20. Review of the facility's undated policy titled Medication Management and Monitoring revealed when a resident receives a new medication, the medication order is evaluated for a written diagnosis, an indication, and/or documented objective findings that support the use of the medication. This deficiency substantiates Complaint Number OH 665.

Based on medical record review and staff interview, the facility failed to ensure a resident's behaviors were being monitored and documented as per the plan of care. This affected one (Resident #70) of three residents reviewed for behaviors. The facility identified 12 residents with behavioral symptoms. The facility census was 71. Findings include: Review of the medical record for Resident #70 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 12/29/19, revealed the resident had mildly impaired cognition. Further review of the resident's medical record revealed [REDACTED]. He had stays at the inpatient behavioral units from 11/13/19 to 11/22/19, 12/18/19 to 12/19/19 and from 01/02/20 through 01/18/20. Review of the resident's plan of care, dated 03/07/19, revealed a plan for behaviors and the resident has the potential to be verbally aggressive a related to ineffective coping skills and poor impulse control and for altered mood pattern related to Dementia, depression and [MEDICAL CONDITION]. His interventions which included to monitor behaviors and document observed behavior and attempted interventions. The medical record did not have any behavior monitoring and/or assessments noted from 01/18/20 through 01/26/20. Interview on 01/27/20 at 11:41 [NAME]M. with Director of Nursing verified the behavior tracking of Resident #70 had not been restarted after his returns from the hospital on [DATE] and should have been completed every shift. Interview with Licensed Practical Nurse #300 on 01/27/20 at 3:50 P.M. revealed the resident should have behavior assessments completed every day due to his behaviors. She has witnessed him having behaviors such as being agitated, he will refuse his medications and will spill and throw stuff on purpose for staff to clean up. She did not realize the behavior assessments had not been restarted since his last admission from the behavioral unit.

Based on medical record review, review of a medication error report, staff, resident and hospital staff interview and policy review, the facility failed to ensure Resident #14 was provided with a safe and orderly discharge when the staff discharged the resident with another resident's (#11) medications. This affected one (#14) out of five residents reviewed for discharge and/or medications. The facility census was 76 residents. Findings include: Review of Resident #14's medical record, revealed he was originally admitted to the facility on [DATE]. Resident #14 was discharged home on[DATE] and readmitted to the facility 10/27/19. [DIAGNOSES REDACTED]. During the admission process, the resident had brought a clear, plastic box to the facility that contained bottles of medications he took while at home. The facility had a policy, Medications Brought to the Facility by the Resident/Family, that did not permit residents and families to bring medications into the facility. The policy stated that medications brought into the facility that are not approved for the resident's use, shall be returned to the family. If the family does not pick up those medications within 30 days, the facility may destroy them in accordance to facility policy. The medications in the clear, plastic box, were stored in the nurses' medication room. The resident received his medications while at the facility through the facility's pharmacy. The medications were sorted by date and time, into small prepackaged bags, which the facility nurse would then pass as ordered. Review of the five day Minimum Data Set ((MDS) dated [DATE], revealed the cognitively intact resident, required limited assistance of staff with bed mobility, transferring, dressing, and toilet use. He was able to feed himself with supervision and required extensive assistance with personal hygiene tasks. Review of the nursing notes dated 10/09/19 at 1:35 P.M., revealed the resident was discharged to his home via transport company. The nurse documented all discharge instructions explained and understood. Review of the Discharge Instructions Part 1 form given to the resident during the discharge, revealed on 10/09/19 Licensed Practical Nurse (LPN) #5 went over the residents' discharge medications with the resident. LPN #5 documented on the discharge form, he was educated on taking his Aspirin 81 milligrams (mg) daily, [MEDICATION NAME] Silver vitamin daily, Fiber tablet 1000 mg daily, [MEDICATION NAME] 20 mg daily (for [MEDICAL CONDITION]), [MEDICATION NAME] 100 mg twice daily (for neural pain), Glimepiride 1 mg daily (for diabetes), [MEDICATION NAME] 15 units injection daily (for diabetes), [MEDICATION NAME] 20 mg daily (for hypercholesterol), [MEDICATION NAME] HandiHaler 15 micro grams (mcg) inhale one puff daily (for [MEDICAL CONDITION]), [MEDICATION NAME] HCL 37.5 mg twice daily (for depression), Vitamin D3 2000 units daily twice daily (supplement), Xtandi 160 mg daily ([MEDICAL CONDITION]), [MEDICATION NAME] ER 12.5 mg twice daily (for hypertension), Tylenol 650 mg every six hours as needed (for pain), and Pantoprazole 40 mg daily (for gastric reflux). The nurse packed approximately two days worth of the resident's prepackaged medications and sent them home along with the plastic container of medications, he brought from his home. On 10/17/19, the resident was sent out to the hospital from his home for reasons unknown. While at the hospital, it was discovered upon discharge from the nursing home on 10/09/19, the resident was given four bottles of medication from another resident (#11) who also resided at the facility. Resident #11 was admitted on [DATE] and also brought medications she used at home that were inadvertent placed with Resident #14's medications in his plastic container. The medications were [MEDICATION NAME] 50 mg three times daily (for hypertension), [MEDICATION NAME] ER 50 mg daily (for hypertension), [MEDICATION NAME] 25 mg daily (a diuretic and anti-hypertensive), and [MEDICATION NAME] 20 mg daily (for gastric reflux). Resident #14 told the hospital staff, he was taking these four medications in addition to the medications he was discharged with. He denied knowing that the medications belonged to another resident. At that time, the facility staff were notified of the medication error by the hospital staff. After being notified of the above error, the facility began an investigation. A Medication Error Report was filed that stated on 10/09/19 at 1:35 P.M., Registered Nurse (RN) #10 and LPN #15 gave Resident #14 his plastic container of medications that he brought in with him at admission. He was given another resident's (#11) medications that were placed in his container along with his own. The medication bottles in the plastic container returned to Resident #14 were not reviewed by RN #10 and LPN #15 as required, prior to releasing them to the resident The nurses stated they did not review the medications in the plastic container with the resident, because the container was labeled with his name. Both nurses were disciplined due to not reviewing the medications prior to giving them to the resident. On 10/27/2019 at 3:00 P.M., the resident was readmitted to the facility from the hospital. Since discharging from the facility on 10/09/19, the resident had been treated at the hospital on three occasions. On the last admission on 10/27/19, the resident was sent to this facility due to increased pain. It was discovered at the hospital, the resident's [MEDICAL CONDITION] had not only metastasized to his lungs but also metastasized to his bones. On 11/05/19 at 9:20 [NAME]M., Resident #14 stated during interview, he was discharged from this facility in (MONTH) to his home. The resident stated his medications were sent home with him in his plastic container he brought in. The resident stated they were the wrong medications. When asked why he would take the wrong medications with another person's name on them, he answered, he really did not pay attention to the labels. The resident stated he started going downhill fast when he got home, which he thought was because of the wrong medications. He also stated, he went in the hospital three times after he was discharged , the first for the wrong medications, the second time for a rash, the third time for the same rash with his throat swelling due to eating a peanut. The hospital's quality assurance nurse (#25) was interviewed via telephone call on 11/05/19 at 9:41 [NAME]M. She stated the Resident #14 came to the hospital on [DATE] with four containers of medication that did not belong to him. The medications belonged to another resident (#11) who resided at the long term care facility the resident was discharged from. The resident told the staff at the hospital, the medications were sent home with him from the long term care facility and he had been taking them daily. The quality assurance nurse stated she notified the nursing facility of this incident. She stated the hospital staff took pictures of the four medications in the resident's possession when he arrived at the hospital that were clearly labeled with Resident #11's name. The surveyor reviewed the pictures via scanned copy. On 11/05/19 at 10:50 [NAME]M., LPN #5 stated during interview, the social worker started the discharge process and typed in all medications he was on. LPN #5 went over the electronic Medication Administration Record [REDACTED]. On 11/05/19 at 11:10 [NAME]M., RN #10 was interviewed and stated she was in a meeting with a hospice agency, and she was asked to go into the medication room and get the resident's container of medications he brought with him upon admission. She stated she saw the resident's name on the container, grabbed it, then handed it to LPN #15 who was discharging the resident and his wife. RN #10 confirmed she did not open the container and check the medications to ensure they belonged to the resident. On 11/05/19 at 12:45 P.M., LPN #15 was interviewed via telephone call. She stated she was pulled from a meeting to help with a discharge. She went into the medication room and pulled out Resident #14's prepackaged medication to send home with the resident. He only had one day left of these prepackaged medications. She also gave the resident his plastic container of medications to take home. The nurse confirmed she did not open the container and go through the medications to make sure they belonged to the resident and to educate the resident on each of the medications and whether to take them or not in accordance to facility policy. She stated she did not open the container, but it was a clear container and she did not see any other residents' medication bottles in the container. During interview with the facility's Administrator on 11/05/19 at 4:50 P.M., she confirmed the nurses who discharged Resident #14, did not check the medications in the container to ensure they belonged to the resident. Review of the facility's policy for Discharge Medications, revealed medications may be sent home with the resident upon discharge if authorized by the prescriber. The labels of discharge medications are verified for completeness and accuracy by checking them against the most recent physician's orders [REDACTED]. This deficiency substantiates Complaint Number OH 940.

Based on medical record review, family interview, staff interview, and review of a facility policy, the facility failed to notify a resident's family of a change in condition. This affected one (Resident #30) of six residents reviewed for abuse prohibition. The facility census was 70. Findings include: Review of Resident #30's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe impairment in cognition. She was at risk for pressure ulcers. She had no unhealed pressure ulcers. She had no moisture associated skin damage. She required extensive assistance with one staff member for transfers, dressing, toilet use, and personal hygiene. She required supervision with one staff for walking in room, locomotion, and bed mobility. Review of the resident's nursing notes revealed an entry dated 07/10/19 at 4:21 P.M. The entry indicated [MEDICAL CONDITION] of the resident's labia was noted which was purple in color. The resident stated there was discomfort. The physician was notified and [MEDICATION NAME] (antifungal medicine) was ordered. The evaluation was, will monitor and have the nurse practitioner look at her tomorrow during rounds. Review of the physician's orders [REDACTED]. Continued review of the resident's medical record revealed [REDACTED]. Interview with Resident #30's power of attorney on 09/24/19 at 10:54 [NAME]M. revealed she was not notified of an area of impairment to the resident's perineal and buttock area. Interview with Registered Nurse #259 on 09/26/19 at 2:21 P.M. verified the resident's POA was not notified when the resident had a change in condition on 07/10/19. Review of an undated facility policy titled Change in a Resident's Condition or Status revealed the facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when the resident is involved in any accident or incident that results in an injury including injuries of an unknown source.

Based on medical record review, review of facility Self-Reported Incidents (SRI), review of a police incident report, staff interviews and review of the facility's Abuse/Neglect/Misappropriation of Resident Property policies and procedures, the facility failed to ensure a cognitively impaired resident was free from physical abuse by a family member during visitations. This resulted in Immediate Jeopardy and the potential for psychosocial harm for one resident (Resident #78) when on 07/01/17, Licensed Practical Nurse (LPN) #300 observed Resident #78's family member (FM) #99, with a known history of physical abuse toward Resident #78, pushing on her throat multiple times. The resident expressed he was hurting her, asked him to stop several times and was observed to look scared. After this occurred, the facility failed to take immediate action to prevent future occurrences and protect the resident from abuse. On 07/04/17, LPN #305 observed FM #99 yelling and twisting Resident #78's right arm, while the resident was yelling out for help that he was hurting her. Resident #78 expressed fear of FM #99 returning and being alone immediately following the occurrence. This affected one (Resident #78) of one residents reviewed for abuse. The facility census was 71. On 08/02/17 at 3:57 P.M., the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and Visiting DON #400 were notified Immediate Jeopardy began on 07/01/17 at 1:37 P.M. when FM #99, with a known history of physical abuse, was observed by LPN #300 pushing on Resident #78's throat multiple times, she was asking him to stop, expressing that it hurt and was observed to look scared. After this occurred, the facility failed to take immediate action to prevent future occurrences and protect the resident from further abuse. On 07/04/17, LPN #305 observed FM #99 yelling at and twisting Resident #78's right arm, and the resident was yelling out for help. Resident #78 expressed fear of FM #99 returning and being alone after this occurrence. The Immediate Jeopardy was removed on 08/03/17 when all staff were in-serviced on the facility abuse policy, the signs of suspicious bruising in the older adult, visitation restrictions, and the facility implemented the following corrective actions: · On 08/02/17 at 2:30 P.M., LPN #305 assessed Resident #78's skin for any suspicious bruising and signs of abuse, with none found. This information was verified via assessment at 6:00 P.M. by the DON. · On 08/02/17 at 4:30 P.M., the LNHA educated all facility department managers, including Dietary, Environmental Services, Therapy, Activities, Nursing, Business Office, Maintenance and Admissions on the visitation restrictions as well as the visitation log for FM #99 for visiting Resident #78, due to the risk of abuse. Supervised visits will be managed by Resident #78's nurse. When the family member arrives, the nurse will assign a staff member to stay in 'line of sight' of Resident #78 until FM #99 leaves the building. The staff member that supervises the visit will sign the visitation log. If another supervisor takes over the visit, the change and time of change will be documented on the visit log. If any staff member feels threatened or concerns for the resident's well-being, the supervising staff member will end the visit. · On 08/02/17 from 5:00 P.M. until 8:00 P.M., the DON, LPN #239, Social Services (SS) #700, Registered Nurse (RN) #200, Housekeeper (HK) #770, Quality Assurance Nurse (QAN) #160, Housekeeping Manager (HKM) #150, and Dietary Manager (DM) #722 educated all facility and therapy staff regarding FM #99's visitation restrictions and visitation log, either in person or by phone. The education included that FM #99 will call the facility the morning of the day to visit, before any visitation, and speak with the resident's nurse. Resident #78's nurse will ask the resident if she would like to speak with her family member on the phone and/or set up a visitation with him. The nurse will inform the family member of Resident #78's wishes. If Resident #78 allows visitation, a time of the visitation will be established. Upon arrival at the facility, FM #99 will enter through the front entrance and alert staff of his presence. The staff member will then alert Resident #78's nurse, who will then have the family member sign the visitation log. All visitations will occur only in the front entrance lobby. Resident #78 will be brought to the front lobby to visit with FM #99, with a staff member supervising at all times. Once the visitation is over, FM #99 will sign out and exit through the front entrance where he first entered. If any observations are made of distress, anger, agitation, or raised voices, staff will ask Resident #78's family member to leave. If Resident #78's family member refuses to leave, staff will call 911 immediately and notify the LNHA and DON. If FM #99 was seen anywhere besides the front entrance, staff will immediately direct him back outside of the facility and notify the LNHA and DON. Resident #78's nurse will document each visitation and phone calls in the resident's chart. · On 08/02/17 at 6:00 P.M., the LNHA educated FM #99 of visiting restrictions and FM #99 voiced understanding. · On 08/02/17 at 6:30 P.M. the LNHA verified that Resident #78 felt secure in the facility, Resident stated Have you seen my husband, tell him I'm going to church. No other statements were made. · On 08/02/17 at 7:00 P.M., the DON posted reminders of the visiting restrictions at the nurse's stations, breakrooms and in the nurse aide binders. · On 08/02/17 at 8:00 P.M. the visitation log was implemented and left at the nurse's station. The LNHA will monitor the visitation log weekly for compliance, with staff nurses monitoring daily. Resident #78 will be assessed by nursing following visits to assure no feeling of fear or insecurity. · On 08/02/17, Resident #78's care plan was updated to reflect the new visiting guidelines. · On 08/03/17, Quality Assurance (QA) audits will be implemented to ensure continuous staff awareness of visiting restrictions and this will be completed weekly, until reassessed for continued need at next scheduled quarterly QA meeting on 09/14/17. · On 08/03/17 by 4:30 P.M., LPN #108, LPN #237, LPN #300, LPN #239, LPN #101 and the DON assessed all other residents residing in the facility for suspicious bruising or signs of abuse, and questioned them regarding feelings of safety and security in the facility. There were no identified problems noted. · On 08/03/17, QA audits will be implemented to ensure continuous staff awareness of signs of resident abuse and will be completed weekly, until reassessed for continued need at the next scheduled quarterly QA meeting on 09/14/17. Issues will be referred to the DON and the LNHA immediately for corrective action/education. Weekly evaluation of staff will be completed to ensure they are aware of the abuse policies and procedures or any current visitor restrictions in place. · On 08/04/17 by 3:00 P.M., the DON will in-service all nursing staff on the signs of suspicious bruising in the older adult. · On 08/03/17 from 6:05 P.M. until 6:15 P.M. interviews with STNA #177, LPN #300, MS #802, Dietary Aide #803 and SS #810 revealed all staff interviewed were knowledgeable of the facility abuse policy and procedure as well as the visiting restrictions for Resident #78 and FM #99. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #78's medical record revealed an original admission date of [DATE] with the most recent re-admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #78's admission assessment dated [DATE] revealed she was not admitted to the facility with a [MEDICAL CONDITION] opening. Review of the Resident #78's care plan (initiated 01/15/17) identified the resident as having ineffective coping related to martial relationship issues and was a client of the in-house mental health counselor one time weekly and as needed. The goal was to maintain safety for this resident with interventions to contact the in-house mental health counselor as needed; document any changes in mood and/or mental status; give medications as per physician orders and provide opportunity for positive interactions. However, there were no care plans in place to ensure safety of the resident. Additionally, there was a care plan for potential for altered communication or impaired verbal communication related to [MEDICAL CONDITION], stroke, verbalizing more and could be understood most of the time. The resident's speech was a soft 'whisper' but can make needs known and can usually understand;[MEDICAL CONDITION] been removed, and speaks in a whisper and can answer. The goal was the resident's needs would be identified and met by staff despite communication deficit. Interventions included to anticipate and meet needs; and stand so you can be seen, speak slowly and distinctly, call the resident by name, use yes/no question and allow adequate response time. Review of the social service note dated 01/16/17 at 5:26 P.M. revealed Resident #78 was admitted to the facility on [DATE] from her home due to alleged abuse from FM #99 and his refusal to allow caregivers to care for her. Review of the mental health diagnostic assessment dated [DATE] identified the resident as being a victim of domestic violence and experienced physical abuse by FM #99. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] identified the resident as being unable to complete the interview to determine a mental status score. It identified the resident as being moderately impaired with decision making regarding tasks of daily life, having short term and long term memory problems and requiring two-person extensive assistance with bed mobility, transfers, and toilet use. It indicated the resident was totally dependent on staff with locomotion on and off the unit. Review of the nurses note dated 07/01/17 at 1:37 P.M. revealed, while LPN #300 was in Resident #78's room flushing her gastrostomy tube ([DEVICE]- a tube inserted through the abdomen that delivers nutrition directly to the stomach) before lunch, she was talking to the resident and FM #99. The note indicated that LPN #300 told the resident to speak louder so she could hear what she was saying. The documentation revealed that FM #99 reached over, put his hand on Resident #78's neck and pushed. The resident told FM #99 to stop several times and pulled away, but he kept doing it. LPN #300 asked Resident #78 if it hurt when he pushed on her throat and Resident #78 stated yes. Further review of the nurses noted revealed Resident #78 had a very scared look on her face and asked the nurse to take her to the dining room. FM #99 proceeded to go to the dining room with the resident. Review of the facility's SRI's revealed there was no SRI regarding the above incident on 07/01/17 nor was there documentation of an investigation. Review of the weekly skin assessment dated [DATE] identified Resident #78 as having no skin areas noted with skin intact and without discoloration. Review of a social service note dated 07/04/17 at 1:58 P.M. revealed LPN #305 was walking towards Resident #78's room around 11:50 A.M. when she heard FM #99 yelling. Upon walking into the resident's room, the nurse observed FM #99 pulling and twisting the resident's right arm forward and yelling put your damn arm down now. The note indicated Resident #78 was yelling get off me, let go, someone help me. It indicated the LPN #305 asked the family member to take his hands off her and asked what was going on; Resident #78 stated he was hurting her. The nurse then had asked if she wanted FM #99 to leave and she stated yes. It revealed the family member was told he could not put his hands on her like that and he was asked to leave for the day. The note further indicated Resident #78 was taken down to the lobby with the nurse and Resident #78 stated that she did not want to go back to her room and asked the nurse if she would stay with her. Resident #78 stated that he was going to come back, and that he was choking her. The resident asked the nurse to not leave her, and she took her to the dining area with other staff members present; Resident #78 was frightened and scared her family member was going to return. Resident #78 was assured FM #99 would not be returning to the building that day. The resident requested the police be called and a report filed. The note indicated the resident also had a bruise on her left cheek, yellow and old in appearance. Resident #78 stated that FM #99 hit her and that was what the bruise was from. Review of the skin investigation form dated 07/04/17 revealed a bruise was noted on the resident's left cheekbone. It revealed the resident's recent change in behavior/cognition was agitation caused by FM #99. It revealed the activity engaged at the time of the event was FM #99 trying to lower the resident's arm. Review of the facility SRI # 7, dated 07/04/17 for physical abuse, which was unsubstantiated by the facility, revealed a staff member witnessed FM #99 pulling and twisting Resident #78's right arm forward and yelling at her to put her arm down now. It identified the resident was scared of FM #99 and was emotionally distressed and fearful. Review of the narrative summary of the incident and the investigation revealed that on 07/04/17 at 11:50 A.M., the nurse heard yelling coming from Resident #78's room and she walked in on the resident's family member pulling and twisting the resident's right arm. When Resident #78's family member was questioned, he stated, She told me her arm hurt and I told her to put it down so I could rub it where it hurt. As Resident #78's family member was doing this, the resident was yelling at him, get off me, let go, someone help me. The nurse intervened immediately and instructed the family member to take his hands off her, and was asked to leave the building. The nurse took the resident to the lobby per her request and the resident stated to the nurse that he was choking her. The nurse then noticed a light-yellow bruise on her left cheek. The resident states, He hit me and that is what the bruise was from. The nurse ensured the resident's safety and notified the DON and Social Services. Resident #78 wanted to file a report and the police were called to come and take a statement. The report stated Resident #78 was very confused about the whole incident with her story changing on how the bruise occurred. It revealed the bruise was first noticed by staff on this day and that the medical director was notified of the incident and discussed the bruise development on the resident's left cheek. It revealed the resident was dependent on staff for all transfers and used a Hoyer lift. Interviews with staff were conducted and reported the resident grabs and moves the Hoyer bars during transfers when educated to cross her arms. As a result of the investigation it identified that all visitation from Resident #78's family member was to be in a public area and upon the resident's approval. Review of the police department incident report dated 07/04/17 revealed on 07/04/17 they were dispatched in reference to a domestic type incident witnessed by a nurse. Upon arrival, the officer met with Resident #78, LPN #305 who witnessed the incident, and the Social Worker. The nurse stated that she overheard arguing or louder talking from Resident #78's room. She then went into the room and observed Resident #78's family member with his hands around the resident's right arm. It indicated that Resident #78 suffers from both physical and mental handicaps. It revealed the officer spoke with the resident and she seemed very confused about the whole incident; at first stated that her family member punched her in the face and leg. It revealed the resident did have an old bruise mark on her face that appeared to be days old. Later the resident stated that the family member had done this in the last week but later again stated she did not know how she got the bruise. The report revealed the social worker and the nurse both confirmed the resident was very confused at times and had mental issues. The report indicated the officer met privately in the hallway with the social worker and the nurse, and a short time later the officer contacted the resident again and asked her what happened during the incident and the resident stated that her family member was spending all their money at the boats. The resident proceeded to say that she got mad and attempted to strike her family member, and then her family member grabbed her by the arm and then the nurse came in. It indicated the Social Worker stated that they would be requiring Resident #78's family member to make visits with the resident in the lobby only and no longer in her room unsupervised. Review of the mental health counseling notes dated 07/06/17 from 9:00 A.M. until 9:20 A.M. identified Resident #78 as tearful and briefly processed the recent event with FM #99. Resident #78 also reported FM #99 pulled her hair because she was not speaking loud enough. Review of the weekly skin assessment dated [DATE] identified Resident #78 was noted with a fading purple bruise to the left cheek. Further review of the medical record failed to indicate this bruise was investigated. Review of the physician note dated 07/14/17 at 4:47 P.M. revealed Resident #78 had a facial bruise and it was unclear of the etiology and had since resolved. Interview with the LNHA and the DON on 08/01/17 at 3:47 P.M. verified the incident that occurred on 07/01/17 between Resident #78 and FM #99 was not investigated. The interview revealed the facility did not consider it abuse as the family member was just showing the nurse how Resident #78 could talk better and that FM #99 was trying to show LPN #300 the resident was able to talk louder, by holding the hole of her [MEDICAL CONDITION]. The DON verified the resident's scared reaction when FM #99 was pressing on her neck, made the nurse question Resident #78 if what he was doing hurt. Knowing their past domestic violence history. The LNHA revealed she didn't feel Resident #78's family member was intentionally trying to harm her. The DON verified Resident #78 was brought to the facility due to abuse at home. Further interview with the DON on 08/01/17 at 4:02 P.M. verified she did not talk to the resident or her family member regarding the incident on 07/01/17 and that LPN #300 did notify her of the situation that occurred. Interview with LPN #300 on 08/01/17 at 7:15 P.M. revealed on 07/01/17 she was in Resident #78's room, finishing up with her G- tube. LPN #300 stated the resident's family member was visiting and lying in her bed, which he usually does when he visits. LPN #300 voiced the resident said something to her and she asked the resident to repeat it, as she could not hear what she said. LPN #300 revealed FM #99 reached around the resident's neck and pushed on the front of her throat four times. She revealed that each time the resident asked him to stop, getting louder each time and by the fourth time she yelled stop. LPN #300 voiced she stepped in and told him to stop and he voiced he was not trying to hurt her, but this was what he did at home to make her talk louder. LPN #300 reported she asked the resident if that hurt her and the resident stated it did hurt. LPN #300 revealed Resident #78 then asked her to take her to the dining room, which she did. LPN #300 stated she called the DON and Social Worker #700 to report the incident and the DON instructed her to document the incident. LPN #300 verified she was concerned for the resident's safety as she thought he was being abusive and she knew there was a history of domestic violence. Interview with Social Worker (SW) #700 on 08/02/17 at 9:00 A.M. revealed that on 07/01/17 she was on vacation and LPN #300 called and informed her of the incident that occurred between Resident #78 and FM #99. SW #700 verified she did not come into the facility to talk to the resident or the resident's family member to follow up on the incident that occurred on 07/01/17. Continued interview with SW #700 revealed on 07/04/17 she was still on vacation and she was again called regarding Resident #78's family member twisting Resident #78's arm. However, she verbalized that she did come in and met with the police officer and Resident #78. SW #700 verbalized that Resident #78 told the police officer that her family member and she were arguing, she hit her family member and then he grabbed her arm. SW #700 voiced they recommended if FM #99 wanted to visit he had to call first, and if Resident #78 wanted him to visit, they would have to be in the lobby. When SW #700 was asked who was supervising the visitor with Resident #78 and her family member, she responded the STNA, a nurse, or someone from the office. Interview with the DON on 08/02/17 at 9:16 A.M. revealed the facility felt the bruise Resident #78 was observed to have on 07/04/17 was in the same area as the one on 07/09/17. The DON voiced that she had spoken with the physician on 07/05/17 regarding Resident #78's bruise to the left cheek. She voiced she asked him how it could be yellow and he voiced if the bleeding was internal then it would show up with a yellow bruise externally. Interview with the LNHA and DON on 08/02/17 at 9:21 A.M. verified the DON notified the LNHA of the incident that occurred on 07/01/17. The DON verbalized that when LPN #300 notified her of the incident she instructed the nurse to explain to her what she felt about the situation and the nurse explained what happened and then asked if the nurse felt the resident was in any harm. The DON voiced that with them knowing the resident and her family member, and knowing the history, that she didn't feel that this incident was intentional. The DON voiced that LPN #300 asked the resident if she wanted her family member to go to the dining room with her on 07/01/17 and resident voiced that was fine, and FM #99 left right after she was finished eating. The DON stated LPN #300 called her because they are told to call and inform them of anything they feel they need notified of. The DON stated on 07/01/17, the resident's family member could visit whenever. Both the LNHA and the DON stated that starting 07/04/17, FM #99 was to call the facility first, and the staff were to ask Resident #78 if she wanted her family to visit; if the resident says yes, then he may visit, but if the resident doesn't want him to visit then he was not allowed to visit. The DON stated that when Resident #78's family member comes and visits, he parks outside of the skilled unit and comes through those entrance doors. She voiced Resident #78 and FM #99 are to sit in the lobby to visit with supervision and supervision was done by an aide, a nurse or one of the office employees. The DON verified there was no place to document when FM #99 visits nor to confirm supervision was completed during these visits. The LNHA stated the staff were educated verbally during shift change regarding FM #99's visits. The DON stated the bruise to the residents left cheek that was present on 07/04/17, was investigated and staff were asked regarding the bruise. She revealed it was identified that the resident uses the Hoyer lift for transfers with getting in and out of the bed and chair. The DON stated the resident grabs the bars on the Hoyer lift 'fearfully' and that the bar could have hit the resident in the face, due to it has hit her in the face in the past. The DON confirmed that on 07/09/17, Resident #78 had a fading purple bruise that was also present to the left side of her cheek that she was unaware was there. The DON confirmed that the yellow bruise to the left side of Resident #78's cheek was not observed prior to it being yellow on 07/04/17 and confirmed she did not investigate the fading purple bruise to Resident #78's left cheek on 07/09/17 due to they felt the bruise was the same one, however was unsure how the bruise went from yellow to purple. The DON also confirmed there was no care plan regarding visitations with FM #99. Interview with State tested Nurse Aide (STNA) #100 on 08/02/17 at 9:35 A.M. revealed that she worked on the skilled unit. STNA #100 revealed that visitors come through the skilled unit entrance doors. STNA #100 stated there are visiting restrictions for FM #99 and if he comes to visit, they are to ask him to leave and if he resists, then they are to get the nurse. Interview with STNA #101 on 08/02/17 at 9:40 A.M. revealed that visitors come through the skilled unit entrance doors. STNA #101 voiced about a month ago there were visiting restrictions for Resident #78. She revealed that if FM #99 came to visit, that they were to ask him to leave. STNA #101 denied currently having any residents who reside in the facility that have visiting restrictions including Resident #78. Interview with STNA #107 on 08/02/17 at 9:42 A.M. revealed when FM #99 visits Resident #78, the staff have to keep a visual check on them and they have to visit in the lobby. STNA #107 voiced that about a week or two ago Resident #78 had a purple bruise on her cheek and that Resident #78 stated her husband hit her. STNA #107 voiced the resident required a Hoyer lift for transfers and the resident holds on during the transfers. STNA #107 denied Resident #78 ever being hit by the Hoyer lift. Interview with LPN #305 on 08/02/17 at 9:40 A.M. revealed there was a plan in place that Resident #78's family member had to call before he visits and this was put in place after the incident that occurred on 07/04/17. LPN #305 voiced the resident's family member calls the nurse on the hallway and informs them what time he wants to visit and if Resident #78 was okay with the family member visiting, then he was permitted to visit. She stated they are not allowed in her room or anywhere private. LPN #305 verified they do not sit with Resident #78 and FM #99 one on one, that staff just has to be in the area. LPN #305 verified she was the nurse who was working on 07/04/17 when the incident occurred between Resident #78 and FM #99. LPN #305 reported that she heard commotion during noon medication pass, so she went to Resident #78's room and witnessed FM #99 using both hands to pull on Resident #78's arm in a downward motion. She stated the resident was yelling 'help me, help me'. LPN #305 said she asked him to remove his hands, which he did. She then brought the resident up in the front with her because the resident was shook up and she reported she called both the DON and SW #700. Interview with STNA #235 on 08/02/17 at 9:40 A.M. revealed the visiting restrictions with Resident #78 and FM #99 included that the resident's door needed to be open when he was at the facility, and that they have to keep a visual check on him when he was visiting. STNA #235 voiced that no one needed to sit with them during visits. STNA #235 denied Resident #78 ever being hit in the face with the Hoyer lift and had never had any concerns during the Hoyer lift with transfers. Interview with LPN #236 on 08/02/17 at 9:43 A.M. revealed visitors do enter through the doors in the skilled unit. LPN #236 denied any residents having any visiting restrictions and denied currently having any residents who currently have visiting restrictions. Interview with LPN #108 on 08/02/17 at 9:45 A.M. revealed when the incident between Resident #78 and FM #99 first happened, they would sit in the lobby and chart, however, since then it's just been a visual check. LPN #108 voiced that on 07/04/17, the resident was very scared and did not want to be left alone. Interview with STNA #401 and STNA #402 on 08/02/17 at 9:58 A.M. revealed they could verbalize the visitation plan in place. Both STNA #401 and STNA #402 reported Resident #78 was nervous and scared using the Hoyer lift for transfers and that she does hang onto the bars, however, they denied being aware of any incident of the resident being hit in the face with the Hoyer lift bar. STNA #401 voiced she noticed Resident #78 bruise to her left check around 07/04/17, however, was unsure how it occurred. Review of the facility policy titled 'Abuse/Neglect/Misappropriation of Resident Property', (undated), identified abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This policy indicated residents of the long term care facility are protected from any physical, mental, sexual mistreatment, neglect or abuse and must ensure that all alleged violations are reported immediately upon discovery of an alleged violation to their direct supervisor. The allegation will be reported immediately or (as soon as possible, but not more than 24 hours after discovery of the incident) to the Administrator or designee. The Administrator or designee will report all alleged violations immediately (as soon as possible, but not more than 24 hours after discovery of the incident) to the state agency and to all other agencies as required. It indicated the results of all investigations must be reported to the Administrator or designee and to the state agency within five working days of the incident. The facility will take all necessary corrective actions depending on the results of the investigation.

Based on review of the medical record, review of facility Self-Reported Incidents (SRI), staff interviews and review of the facility's Abuse/Neglect/Misappropriation of Resident Property policies and procedures, the facility failed to report and investigate an incident of physical abuse for cognitively impaired resident and ensure she was free from physical abuse by a family member during visitations. This resulted in Immediate Jeopardy and the potential for psychosocial harm for one resident (Resident #78) when on 07/01/17, Licensed Practical Nurse (LPN) #300 observed Resident #78's family member (FM) #99, with a known history of physical abuse toward Resident #78, pushing on her throat multiple times. The resident expressed he was hurting her, asked him to stop several times and was observed to look scared. After this occurred, the facility failed to take immediate action to prevent future occurrences and protect the resident from abuse. On 07/04/17, LPN #305 observed FM #99 yelling and twisting Resident #78's right arm, while the resident was yelling out for help and that he was hurting her. Resident #78 experienced fear of FM #99 returning and being alone immediately following the occurrence. This affected one (Resident #78) of one residents reviewed for abuse. The facility census was 71. On 08/02/17 at 3:57 P.M., the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and Visiting DON #400 were notified Immediate Jeopardy began on 07/01/17 at 1:37 P.M. when FM #99, with a known history of physical abuse, was observed by LPN #300 pushing on Resident #78's throat multiple times, she was asking him to stop, expressing that it hurt and was observed to look scared. After this occurred, the facility failed to take immediate action to prevent future occurrences and protect the resident from further abuse. On 07/04/17, FM #99 was observed by LPN #305 yelling at and twisting Resident #78's right arm, and the resident was yelling out for help. Resident #78 experienced fear of FM #99 returning and being alone after this occurrence. The Immediate Jeopardy was removed on 08/03/17 when all staff were in-serviced on the facility abuse policy, the signs of suspicious bruising in the older adult, visitation restrictions, and the facility implemented the following corrective actions: · On 08/02/17 at 2:30 P.M., LPN #305 assessed Resident #78's skin for any suspicious bruising and signs of abuse, with none found. This information was verified via assessment at 6:00 P.M. by the DON. · On 08/02/17 at 4:30 P.M., the LNHA educated all facility department managers, including Dietary, Environmental Services, Therapy, Activities, Nursing, Business Office, Maintenance and Admissions on the visitation restrictions as well as the visitation log for FM #99 for visiting Resident #78, due to the risk of abuse. Supervised visits will be managed by Resident #78's nurse. When the family member arrives, the nurse will assign a staff member to stay in 'line of sight' of Resident #78 until FM #99 leaves the building. The staff member that supervises the visit will sign the visitation log. If another supervisor takes over the visit, the change and time of change will be documented on the visit log. If any staff member feels threatened or concerns for the resident's well-being, the supervising staff member will end the visit. · On 08/02/17 from 5:00 P.M. until 8:00 P.M., the DON, LPN #239, Social Services (SS) #700, Registered Nurse (RN) #200, Housekeeper (HK) #770, Quality Assurance Nurse (QAN) #160, Housekeeping Manager (HKM) #150, and Dietary Manager (DM) #722 educated all facility and therapy staff regarding FM #99's visitation restrictions and visitation log, either in person or by phone. The education included that FM #99 will call the facility the morning of the day to visit, before any visitation, and speak with the resident's nurse. Resident #78's nurse will ask the resident if she would like to speak with her family member on the phone and/or set up a visitation with him. The nurse will inform the family member of Resident #78's wishes. If Resident #78 allows visitation, a time of the visitation will be established. Upon arrival at the facility, FM #99 will enter through the front entrance and alert staff of his presence. The staff member will then alert Resident #78's nurse, who will then have the family member sign the visitation log. All visitations will occur only in the front entrance lobby. Resident #78 will be brought to the front lobby to visit with FM #99, with a staff member supervising at all times. Once the visitation is over, FM #99 will sign out and exit through the front entrance where he first entered. If any observations are made of distress, anger, agitation, or raised voices, staff will ask Resident #78's family member to leave. If Resident #78's family member refuses to leave, staff will call 911 immediately and notify the LNHA and DON. If FM #99 was seen anywhere besides the front entrance, staff will immediately direct him back outside of the facility and notify the LNHA and DON. Resident #78's nurse will document each visitation and phone calls in the resident's chart. · On 08/02/17 at 6:00 P.M., the LNHA educated FM #99 of visiting restrictions and FM #99 voiced understanding. · On 08/02/17 at 6:30 P.M. the LNHA verified that Resident #78 felt secure in the facility, Resident stated Have you seen my husband, tell him I'm going to church. No other statements were made. · On 08/02/17 at 7:00 P.M., the DON posted reminders of the visiting restrictions at the nurse's stations, breakrooms and in the nurse aide binders. · On 08/02/17 at 8:00 P.M. the visitation log was implemented and left at the nurse's station. The LNHA will monitor the visitation log weekly for compliance, with staff nurses monitoring daily. Resident #78 will be assessed by nursing following visits to assure no feeling of fear or insecurity. · On 08/02/17, Resident #78's care plan was updated to reflect the new visiting guidelines. · On 08/03/17, Quality Assurance (QA) audits will be implemented to ensure continuous staff awareness of visiting restrictions and this will be completed weekly, until reassessed for continued need at next scheduled quarterly QA meeting on 09/14/17. · On 08/03/17 by 4:30 P.M., LPN #108, LPN #237, LPN #300, LPN #239, LPN #101 and the DON assessed all other residents residing in the facility for suspicious bruising or signs of abuse, and questioned them regarding feelings of safety and security in the facility. There were no identified problems noted. · On 08/03/17, QA audits will be implemented to ensure continuous staff awareness of signs of resident abuse and will be completed weekly, until reassessed for continued need at the next scheduled quarterly QA meeting on 09/14/17. Issues will be referred to the DON and the LNHA immediately for corrective action/education. Weekly evaluation of staff will be completed to ensure they are aware of the abuse policies and procedures or any current visitor restrictions in place. · On 08/04/17 by 3:00 P.M., the DON will in-service all nursing staff on the signs of suspicious bruising in the older adult. · On 08/03/17 from 6:05 P.M. until 6:15 P.M. interviews with STNA #177, LPN #300, MS #802, Dietary Aide #803 and SS #810 revealed all staff interviewed were knowledgeable of the facility abuse policy and procedure as well as the visiting restrictions for Resident #78 and FM #99. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #78's medical record revealed an original admission date of [DATE] with the most recent re-admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #78's admission assessment dated [DATE] revealed she was not admitted to the facility with a [MEDICAL CONDITION] opening. Review of the Resident #78's care plan (initiated 01/15/17) identified the resident as having ineffective coping related to martial relationship issues and was a client of the in-house mental health counselor one time weekly and as needed. The goal was to maintain safety for this resident with interventions to contact the in-house mental health counselor as needed; document any changes in mood and/or mental status; give medications as per physician orders and provide opportunity for positive interactions. However, there were no care plans in place to ensure safety of the resident. Additionally, there was a care plan for potential for altered communication or impaired verbal communication related to [MEDICAL CONDITION], stroke, verbalizing more and could be understood most of the time. The resident's speech was a soft 'whisper' but can make needs known and can usually understand;[MEDICAL CONDITION] been removed, and speaks in a whisper and can answer. The goal was the resident's needs would be identified and met by staff despite communication deficit. Interventions included to anticipate and meet needs; and stand so you can be seen, speak slowly and distinctly, call the resident by name, use yes/no question and allow adequate response time. Review of the social service note dated 01/16/17 at 5:26 P.M. revealed Resident #78 was admitted to the facility on [DATE] from her home due to alleged abuse from FM #99 and his refusal to allow caregivers to care for her. Review of the mental health diagnostic assessment dated [DATE] identified the resident as being a victim of domestic violence and experienced physical abuse by FM #99. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] identified the resident as being unable to complete the interview to determine a mental status score. It identified the resident as being moderately impaired with decision making regarding tasks of daily life, having short term and long term memory problems and requiring two-person extensive assistance with bed mobility, transfers, and toilet use. It indicated the resident was totally dependent on staff with locomotion on and off the unit. Review of the nurses note dated 07/01/17 at 1:37 P.M. revealed, while LPN #300 was in Resident #78's room flushing her gastrostomy tube ([DEVICE]- a tube inserted through the abdomen that delivers nutrition directly to the stomach) before lunch, she was talking to the resident and FM #99. The note indicated that LPN #300 told the resident to speak louder so she could hear what she was saying. The documentation revealed that FM #99 reached over, put his hand on Resident #78's neck and pushed. The resident told FM #99 to stop several times and pulled away, but he kept doing it. LPN #300 asked Resident #78 if it hurt when he pushed on her throat and Resident #78 stated yes. Further review of the nurses noted revealed Resident #78 had a very scared look on her face and asked the nurse to take her to the dining room. FM #99 proceeded to go to the dining room with the resident. Review of the facility's SRI's revealed there was no SRI regarding the above incident on 07/01/17 nor was there documentation of an investigation. Review of the weekly skin assessment dated [DATE] identified Resident #78 as having no skin areas noted with skin intact and without discoloration. Review of a social service note dated 07/04/17 at 1:58 P.M. revealed LPN #305 was walking towards Resident #78's room around 11:50 A.M. when she heard FM #99 yelling. Upon walking into the resident's room, the nurse observed FM #99 pulling and twisting the resident's right arm forward and yelling put your damn arm down now. The note indicated Resident #78 was yelling get off me, let go, someone help me. It indicated the LPN #305 asked the family member to take his hands off her and asked what was going on; Resident #78 stated he was hurting her. The nurse then had asked if she wanted FM #99 to leave and she stated yes. It revealed the family member was told he could not put his hands on her like that and he was asked to leave for the day. The note further indicated Resident #78 was taken down to the lobby with the nurse and Resident #78 stated that she did not want to go back to her room and asked the nurse if she would stay with her. Resident #78 stated that he was going to come back, and that he was choking her. The resident asked the nurse to not leave her, and she took her to the dining area with other staff members present; Resident #78 was frightened and scared her family member was going to return. Resident #78 was assured FM #99 would not be returning to the building that day. The resident requested the police be called and a report filed. The note indicated the resident also had a bruise on her left cheek, yellow and old in appearance. Resident #78 stated that FM #99 hit her and that was what the bruise was from. Review of the skin investigation form dated 07/04/17 revealed a bruise was noted on the resident's left cheekbone. It revealed the resident's recent change in behavior/cognition was agitation caused by FM #99. It revealed the activity engaged at the time of the event was FM #99 trying to lower the resident's arm. Review of the facility SRI # 7, dated 07/04/17 for physical abuse, which was unsubstantiated by the facility, revealed a staff member witnessed FM #99 pulling and twisting Resident #78's right arm forward and yelling at her to put her arm down now. It identified the resident was scared of FM #99 and was emotionally distressed and fearful. Review of the narrative summary of the incident and the investigation revealed that on 07/04/17 at 11:50 A.M., the nurse heard yelling coming from Resident #78's room and she walked in on the resident's family member pulling and twisting the resident's right arm. When Resident #78's family member was questioned, he stated, She told me her arm hurt and I told her to put it down so I could rub it where it hurt. As Resident #78's family member was doing this, the resident was yelling at him, get off me, let go, someone help me. The nurse intervened immediately and instructed the family member to take his hands off her, and was asked to leave the building. The nurse took the resident to the lobby per her request and the resident stated to the nurse that he was choking her. The nurse then noticed a light-yellow bruise on her left cheek. The resident states, He hit me and that is what the bruise was from. The nurse ensured the resident's safety and notified the DON and Social Services. Resident #78 wanted to file a report and the police were called to come and take a statement. The report stated Resident #78 was very confused about the whole incident with her story changing on how the bruise occurred. It revealed the bruise was first noticed by staff on this day and that the medical director was notified of the incident and discussed the bruise development on the resident's left cheek. It revealed the resident was dependent on staff for all transfers and used a Hoyer lift. Interviews with staff were conducted and reported the resident grabs and moves the Hoyer bars during transfers when educated to cross her arms. As a result of the investigation it identified that all visitation from Resident #78's family member was to be in a public area and upon the resident's approval. Review of the police department incident report dated 07/04/17 revealed on 07/04/17 they were dispatched in reference to a domestic type incident witnessed by a nurse. Upon arrival, the officer met with Resident #78, LPN #305 who witnessed the incident, and the Social Worker. The nurse stated that she overheard arguing or louder talking from Resident #78's room. She then went into the room and observed Resident #78's family member with his hands around the resident's right arm. It indicated that Resident #78 suffers from both physical and mental handicaps. It revealed the officer spoke with the resident and she seemed very confused about the whole incident; at first stated that her family member punched her in the face and leg. It revealed the resident did have an old bruise mark on her face that appeared to be days old. Later the resident stated that the family member had done this in the last week but later again stated she did not know how she got the bruise. The report revealed the social worker and the nurse both confirmed the resident was very confused at times and had mental issues. The report indicated the officer met privately in the hallway with the social worker and the nurse, and a short time later the officer contacted the resident again and asked her what happened during the incident and the resident stated that her family member was spending all their money at the boats. The resident proceeded to say that she got mad and attempted to strike her family member, and then her family member grabbed her by the arm and then the nurse came in. It indicated the Social Worker stated that they would be requiring Resident #78's family member to make visits with the resident in the lobby only and no longer in her room unsupervised. Review of the mental health counseling notes dated 07/06/17 from 9:00 A.M. until 9:20 A.M. identified Resident #78 as tearful and briefly processed the recent event with FM #99. Resident #78 also reported FM #99 pulled her hair because she was not speaking loud enough. Review of the weekly skin assessment dated [DATE] identified Resident #78 was noted with a fading purple bruise to the left cheek. Further review of the medical record failed to indicate this bruise was investigated. Review of the physician note dated 07/14/17 at 4:47 P.M. revealed Resident #78 had a facial bruise and it was unclear of the etiology and had since resolved. Interview with the LNHA and the DON on 08/01/17 at 3:47 P.M. verified the incident that occurred on 07/01/17 between Resident #78 and FM #99 was not investigated. The interview revealed the facility did not consider it abuse as the family member was just showing the nurse how Resident #78 could talk better and that FM #99 was trying to show LPN #300 the resident was able to talk louder, by holding the hole of her [MEDICAL CONDITION]. The DON verified the resident's scared reaction when FM #99 was pressing on her neck, made the nurse question Resident #78 if what he was doing hurt. Knowing their past domestic violence history. The LNHA revealed she didn't feel Resident #78's family member was intentionally trying to harm her. The DON verified Resident #78 was brought to the facility due to abuse at home. Further interview with the DON on 08/01/17 at 4:02 P.M. verified she did not talk to the resident or her family member regarding the incident on 07/01/17 and that LPN #300 did notify her of the situation that occurred. Interview with LPN #300 on 08/01/17 at 7:15 P.M. revealed on 07/01/17 she was in Resident #78's room, finishing up with her G- tube. LPN #300 stated the resident's family member was visiting and lying in her bed, which he usually does when he visits. LPN #300 voiced the resident said something to her and she asked the resident to repeat it, as she could not hear what she said. LPN #300 revealed FM #99 reached around the resident's neck and pushed on the front of her throat four times. She revealed that each time the resident asked him to stop, getting louder each time and by the fourth time she yelled stop. LPN #300 voiced she stepped in and told him to stop and he voiced he was not trying to hurt her, but this was what he did at home to make her talk louder. LPN #300 reported she asked the resident if that hurt her and the resident stated it did hurt. LPN #300 revealed Resident #78 then asked her to take her to the dining room, which she did. LPN #300 stated she called the DON and Social Worker #700 to report the incident and the DON instructed her to document the incident. LPN #300 verified she was concerned for the resident's safety as she thought he was being abusive and she knew there was a history of domestic violence. Interview with Social Worker (SW) #700 on 08/02/17 at 9:00 A.M. revealed that on 07/01/17 she was on vacation and LPN #300 called and informed her of the incident that occurred between Resident #78 and FM #99. SW #700 verified she did not come into the facility to talk to the resident or the resident's family member to follow up on the incident that occurred on 07/01/17. Continued interview with SW #700 revealed on 07/04/17 she was still on vacation and she was again called regarding Resident #78's family member twisting Resident #78's arm. However, she verbalized that she did come in and met with the police officer and Resident #78. SW #700 verbalized that Resident #78 told the police officer that her family member and she were arguing, she hit her family member and then he grabbed her arm. SW #700 voiced they recommended if FM #99 wanted to visit he had to call first, and if Resident #78 wanted him to visit, they would have to be in the lobby. When SW #700 was asked who was supervising the visitor with Resident #78 and her family member, she responded the STNA, a nurse, or someone from the office. Interview with the DON on 08/02/17 at 9:16 A.M. revealed the facility felt the bruise Resident #78 was observed to have on 07/04/17 was in the same area as the one on 07/09/17. The DON voiced that she had spoken with the physician on 07/05/17 regarding Resident #78's bruise to the left cheek. She voiced she asked him how it could be yellow and he voiced if the bleeding was internal then it would show up with a yellow bruise externally. Interview with the LNHA and DON on 08/02/17 at 9:21 A.M. verified the DON notified the LNHA of the incident that occurred on 07/01/17. The DON verbalized that when LPN #300 notified her of the incident she instructed the nurse to explain to her what she felt about the situation and the nurse explained what happened and then asked if the nurse felt the resident was in any harm. The DON voiced that with them knowing the resident and her family member, and knowing the history, that she didn't feel that this incident was intentional. The DON voiced that LPN #300 asked the resident if she wanted her family member to go to the dining room with her on 07/01/17 and resident voiced that was fine, and FM #99 left right after she was finished eating. The DON stated LPN #300 called her because they are told to call and inform them of anything they feel they need notified of. The DON stated on 07/01/17, the resident's family member could visit whenever. Both the LNHA and the DON stated that starting 07/04/17, FM #99 was to call the facility first, and the staff were to ask Resident #78 if she wanted her family to visit; if the resident says yes, then he may visit, but if the resident doesn't want him to visit then he was not allowed to visit. The DON stated that when Resident #78's family member comes and visits, he parks outside of the skilled unit and comes through those entrance doors. She voiced Resident #78 and FM #99 are to sit in the lobby to visit with supervision and supervision was done by an aide, a nurse or one of the office employees. The DON verified there was no place to document when FM #99 visits nor to confirm supervision was completed during these visits. The LNHA stated the staff were educated verbally during shift change regarding FM #99's visits. The DON stated the bruise to the residents left cheek that was present on 07/04/17, was investigated and staff were asked regarding the bruise. She revealed it was identified that the resident uses the Hoyer lift for transfers with getting in and out of the bed and chair. The DON stated the resident grabs the bars on the Hoyer lift 'fearfully' and that the bar could have hit the resident in the face, due to it has hit her in the face in the past. The DON confirmed that on 07/09/17, Resident #78 had a fading purple bruise that was also present to the left side of her cheek that she was unaware was there. The DON confirmed that the yellow bruise to the left side of Resident #78's cheek was not observed prior to it being yellow on 07/04/17 and confirmed she did not investigate the fading purple bruise to Resident #78's left cheek on 07/09/17 due to they felt the bruise was the same one, however was unsure how the bruise went from yellow to purple. The DON also confirmed there was no care plan regarding visitations with FM #99. Interview with State tested Nurse Aide (STNA) #100 on 08/02/17 at 9:35 A.M. revealed that she worked on the skilled unit. STNA #100 revealed that visitors come through the skilled unit entrance doors. STNA #100 stated there are visiting restrictions for FM #99 and if he comes to visit, they are to ask him to leave and if he resists, then they are to get the nurse. Interview with STNA #101 on 08/02/17 at 9:40 A.M. revealed that visitors come through the skilled unit entrance doors. STNA #101 voiced about a month ago there were visiting restrictions for Resident #78. She revealed that if FM #99 came to visit, that they were to ask him to leave. STNA #101 denied currently having any residents who reside in the facility that have visiting restrictions including Resident #78. Interview with STNA #107 on 08/02/17 at 9:42 A.M. revealed when FM #99 visits Resident #78, the staff have to keep a visual check on them and they have to visit in the lobby. STNA #107 voiced that about a week or two ago Resident #78 had a purple bruise on her cheek and that Resident #78 stated her husband hit her. STNA #107 voiced the resident required a Hoyer lift for transfers and the resident holds on during the transfers. STNA #107 denied Resident #78 ever being hit by the Hoyer lift. Interview with LPN #305 on 08/02/17 at 9:40 A.M. revealed there was a plan in place that Resident #78's family member had to call before he visits and this was put in place after the incident that occurred on 07/04/17. LPN #305 voiced the resident's family member calls the nurse on the hallway and informs them what time he wants to visit and if Resident #78 was okay with the family member visiting, then he was permitted to visit. She stated they are not allowed in her room or anywhere private. LPN #305 verified they do not sit with Resident #78 and FM #99 one on one, that staff just has to be in the area. LPN #305 verified she was the nurse who was working on 07/04/17 when the incident occurred between Resident #78 and FM #99. LPN #305 reported that she heard commotion during noon medication pass, so she went to Resident #78's room and witnessed FM #99 using both hands to pull on Resident #78's arm in a downward motion. She stated the resident was yelling 'help me, help me'. LPN #305 said she asked him to remove his hands, which he did. She then brought the resident up in the front with her because the resident was shook up and she reported she called both the DON and SW #700. Interview with STNA #235 on 08/02/17 at 9:40 A.M. revealed the visiting restrictions with Resident #78 and FM #99 included that the resident's door needed to be open when he was at the facility, and that they have to keep a visual check on him when he was visiting. STNA #235 voiced that no one needed to sit with them during visits. STNA #235 denied Resident #78 ever being hit in the face with the Hoyer lift and had never had any concerns during the Hoyer lift with transfers. Interview with LPN #236 on 08/02/17 at 9:43 A.M. revealed visitors do enter through the doors in the skilled unit. LPN #236 denied any residents having any visiting restrictions and denied currently having any residents who currently have visiting restrictions. Interview with LPN #108 on 08/02/17 at 9:45 A.M. revealed when the incident between Resident #78 and FM #99 first happened, they would sit in the lobby and chart, however, since then it's just been a visual check. LPN #108 voiced that on 07/04/17, the resident was very scared and did not want to be left alone. Interview with STNA #401 and STNA #402 on 08/02/17 at 9:58 A.M. revealed they could verbalize the visitation plan in place. Both STNA #401 and STNA #402 reported Resident #78 was nervous and scared using the Hoyer lift for transfers and that she does hang onto the bars, however, they denied being aware of any incident of the resident being hit in the face with the Hoyer lift bar. STNA #401 voiced she noticed Resident #78 bruise to her left check around 07/04/17, however, was unsure how it occurred. Review of the facility policy titled 'Abuse/Neglect/Misappropriation of Resident Property', (undated), identified abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This policy indicated residents of the long term care facility are protected from any physical, mental, sexual mistreatment, neglect or abuse and must ensure that all alleged violations are reported immediately upon discovery of an alleged violation to their direct supervisor. The allegation will be reported immediately or (as soon as possible, but not more than 24 hours after discovery of the incident) to the Administrator or designee. The Administrator or designee will report all alleged violations immediately (as soon as possible, but not more than 24 hours after discovery of the incident) to the state agency and to all other agencies as required. It indicated the results of all investigations must be reported to the Administrator or designee and to the state agency within five working days of the incident. The facility will take all necessary corrective actions depending on the results of the investigation.

Based on review of the medical record, review of facility Self-Reported Incidents (SRI), staff interviews and review of the facility's Abuse/Neglect/Misappropriation of Resident Property policies and procedures, the facility failed to implement their abuse policy and procedure to report and investigate an incident of physical abuse and ensure a cognitively impaired resident was free from physical abuse by a family member during visitations. This resulted in Immediate Jeopardy and the potential for psychosocial harm for one resident (Resident #78) when on 07/01/17, Licensed Practical Nurse (LPN) #300 observed Resident #78's family member (FM) #99, with a known history of physical abuse toward Resident #78, pushing on her throat multiple times. The resident expressed he was hurting her, asked him to stop several times and was observed to look scared. After this occurred, the facility failed to take immediate action to prevent future occurrences and protect the resident from abuse. On 07/04/17, LPN #305 observed FM #99 yelling and twisting Resident #78's right arm, while the resident was yelling out for help and saying that he was hurting her. Resident #78 expressed fear of FM #99 returning and being alone immediately following the occurrence. This affected one (Resident #78) of one residents reviewed for abuse. The facility census was 71. On 08/02/17 at 3:57 P.M., the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and Visiting DON #400 were notified Immediate Jeopardy began on 07/01/17 at 1:37 P.M. when FM #99, with a known history of physical abuse, was observed by LPN #300 pushing on Resident #78's throat multiple times, she was asking him to stop, expressing that it hurt and was observed to look scared. After this occurred, the facility failed to take immediate action to prevent future occurrences and protect the resident from further abuse. On 07/04/17, LPN #305 observed FM#99 yelling at and twisting Resident #78's right arm, and the resident was yelling out for help. Resident #78 expressed fear of FM #99 returning and being alone after this occurrence. The Immediate Jeopardy was removed on 08/03/17 when all staff were in-serviced on the facility abuse policy, the signs of suspicious bruising in the older adult, visitation restrictions, and the facility implemented the following corrective actions: · On 08/02/17 at 2:30 P.M., LPN #305 assessed Resident #78's skin for any suspicious bruising and signs of abuse, with none found. This information was verified via assessment at 6:00 P.M. by the DON. · On 08/02/17 at 4:30 P.M., the LNHA educated all facility department managers, including Dietary, Environmental Services, Therapy, Activities, Nursing, Business Office, Maintenance and Admissions on the visitation restrictions as well as the visitation log for FM #99 for visiting Resident #78, due to the risk of abuse. Supervised visits will be managed by Resident #78's nurse. When the family member arrives, the nurse will assign a staff member to stay in 'line of sight' of Resident #78 until FM #99 leaves the building. The staff member that supervises the visit will sign the visitation log. If another supervisor takes over the visit, the change and time of change will be documented on the visit log. If any staff member feels threatened or concerns for the resident's well-being, the supervising staff member will end the visit. · On 08/02/17 from 5:00 P.M. until 8:00 P.M., the DON, LPN #239, Social Services (SS) #700, Registered Nurse (RN) #200, Housekeeper (HK) #770, Quality Assurance Nurse (QAN) #160, Housekeeping Manager (HKM) #150, and Dietary Manager (DM) #722 educated all facility and therapy staff regarding FM #99's visitation restrictions and visitation log, either in person or by phone. The education included that FM #99 will call the facility the morning of the day to visit, before any visitation, and speak with the resident's nurse. Resident #78's nurse will ask the resident if she would like to speak with her family member on the phone and/or set up a visitation with him. The nurse will inform the family member of Resident #78's wishes. If Resident #78 allows visitation, a time of the visitation will be established. Upon arrival at the facility, FM #99 will enter through the front entrance and alert staff of his presence. The staff member will then alert Resident #78's nurse, who will then have the family member sign the visitation log. All visitations will occur only in the front entrance lobby. Resident #78 will be brought to the front lobby to visit with FM #99, with a staff member supervising at all times. Once the visitation is over, FM #99 will sign out and exit through the front entrance where he first entered. If any observations are made of distress, anger, agitation, or raised voices, staff will ask Resident #78's family member to leave. If Resident #78's family member refuses to leave, staff will call 911 immediately and notify the LNHA and DON. If FM #99 was seen anywhere besides the front entrance, staff will immediately direct him back outside of the facility and notify the LNHA and DON. Resident #78's nurse will document each visitation and phone calls in the resident's chart. · On 08/02/17 at 6:00 P.M., the LNHA educated FM #99 of visiting restrictions and FM #99 voiced understanding. · On 08/02/17 at 6:30 P.M. the LNHA verified that Resident #78 felt secure in the facility, Resident stated Have you seen my husband, tell him I'm going to church. No other statements were made. · On 08/02/17 at 7:00 P.M., the DON posted reminders of the visiting restrictions at the nurse's stations, breakrooms and in the nurse aide binders. · On 08/02/17 at 8:00 P.M. the visitation log was implemented and left at the nurse's station. The LNHA will monitor the visitation log weekly for compliance, with staff nurses monitoring daily. Resident #78 will be assessed by nursing following visits to assure no feeling of fear or insecurity. · On 08/02/17, Resident #78's care plan was updated to reflect the new visiting guidelines. · On 08/03/17, Quality Assurance (QA) audits will be implemented to ensure continuous staff awareness of visiting restrictions and this will be completed weekly, until reassessed for continued need at next scheduled quarterly QA meeting on 09/14/17. · On 08/03/17 by 4:30 P.M., LPN #108, LPN #237, LPN #300, LPN #239, LPN #101 and the DON assessed all other residents residing in the facility for suspicious bruising or signs of abuse, and questioned them regarding feelings of safety and security in the facility. There were no identified problems noted. · On 08/03/17, QA audits will be implemented to ensure continuous staff awareness of signs of resident abuse and will be completed weekly, until reassessed for continued need at the next scheduled quarterly QA meeting on 09/14/17. Issues will be referred to the DON and the LNHA immediately for corrective action/education. Weekly evaluation of staff will be completed to ensure they are aware of the abuse policies and procedures or any current visitor restrictions in place. · On 08/04/17 by 3:00 P.M., the DON will in-service all nursing staff on the signs of suspicious bruising in the older adult. · On 08/03/17 from 6:05 P.M. until 6:15 P.M. interviews with STNA #177, LPN #300, MS #802, Dietary Aide #803 and SS #810 revealed all staff interviewed were knowledgeable of the facility abuse policy and procedure as well as the visiting restrictions for Resident #78 and FM #99. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #78's medical record revealed an original admission date of [DATE] with the most recent re-admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #78's admission assessment dated [DATE] revealed she was not admitted to the facility with a [MEDICAL CONDITION] opening. Review of the Resident #78's care plan (initiated 01/15/17) identified the resident as having ineffective coping related to martial relationship issues and was a client of the in-house mental health counselor one time weekly and as needed. The goal was to maintain safety for this resident with interventions to contact the in-house mental health counselor as needed; document any changes in mood and/or mental status; give medications as per physician orders and provide opportunity for positive interactions. However, there were no care plans in place to ensure safety of the resident. Additionally, there was a care plan for potential for altered communication or impaired verbal communication related to [MEDICAL CONDITION], stroke, verbalizing more and could be understood most of the time. The resident's speech was a soft 'whisper' but can make needs known and can usually understand;[MEDICAL CONDITION] been removed, and speaks in a whisper and can answer. The goal was the resident's needs would be identified and met by staff despite communication deficit. Interventions included to anticipate and meet needs; and stand so you can be seen, speak slowly and distinctly, call the resident by name, use yes/no question and allow adequate response time. Review of the social service note dated 01/16/17 at 5:26 P.M. revealed Resident #78 was admitted to the facility on [DATE] from her home due to alleged abuse from FM #99 and his refusal to allow caregivers to care for her. Review of the mental health diagnostic assessment dated [DATE] identified the resident as being a victim of domestic violence and experienced physical abuse by FM #99. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] identified the resident as being unable to complete the interview to determine a mental status score. It identified the resident as being moderately impaired with decision making regarding tasks of daily life, having short term and long term memory problems and requiring two-person extensive assistance with bed mobility, transfers, and toilet use. It indicated the resident was totally dependent on staff with locomotion on and off the unit. Review of the nurses note dated 07/01/17 at 1:37 P.M. revealed, while LPN #300 was in Resident #78's room flushing her gastrostomy tube ([DEVICE]- a tube inserted through the abdomen that delivers nutrition directly to the stomach) before lunch, she was talking to the resident and FM #99. The note indicated that LPN #300 told the resident to speak louder so she could hear what she was saying. The documentation revealed that FM #99 reached over, put his hand on Resident #78's neck and pushed. The resident told FM #99 to stop several times and pulled away, but he kept doing it. LPN #300 asked Resident #78 if it hurt when he pushed on her throat and Resident #78 stated yes. Further review of the nurses noted revealed Resident #78 had a very scared look on her face and asked the nurse to take her to the dining room. FM #99 proceeded to go to the dining room with the resident. Review of the facility's SRI's revealed there was no SRI regarding the above incident on 07/01/17 nor was there documentation of an investigation. Review of the weekly skin assessment dated [DATE] identified Resident #78 as having no skin areas noted with skin intact and without discoloration. Review of a social service note dated 07/04/17 at 1:58 P.M. revealed LPN #305 was walking towards Resident #78's room around 11:50 A.M. when she heard FM #99 yelling. Upon walking into the resident's room, the nurse observed FM #99 pulling and twisting the resident's right arm forward and yelling put your damn arm down now. The note indicated Resident #78 was yelling get off me, let go, someone help me. It indicated the LPN #305 asked the family member to take his hands off her and asked what was going on; Resident #78 stated he was hurting her. The nurse then had asked if she wanted FM #99 to leave and she stated yes. It revealed the family member was told he could not put his hands on her like that and he was asked to leave for the day. The note further indicated Resident #78 was taken down to the lobby with the nurse and Resident #78 stated that she did not want to go back to her room and asked the nurse if she would stay with her. Resident #78 stated that he was going to come back, and that he was choking her. The resident asked the nurse to not leave her, and she took her to the dining area with other staff members present; Resident #78 was frightened and scared her family member was going to return. Resident #78 was assured FM #99 would not be returning to the building that day. The resident requested the police be called and a report filed. The note indicated the resident also had a bruise on her left cheek, yellow and old in appearance. Resident #78 stated that FM #99 hit her and that was what the bruise was from. Review of the skin investigation form dated 07/04/17 revealed a bruise was noted on the resident's left cheekbone. It revealed the resident's recent change in behavior/cognition was agitation caused by FM #99. It revealed the activity engaged at the time of the event was FM #99 trying to lower the resident's arm. Review of the facility SRI # 7, dated 07/04/17 for physical abuse, which was unsubstantiated by the facility, revealed a staff member witnessed FM #99 pulling and twisting Resident #78's right arm forward and yelling at her to put her arm down now. It identified the resident was scared of FM #99 and was emotionally distressed and fearful. Review of the narrative summary of the incident and the investigation revealed that on 07/04/17 at 11:50 A.M., the nurse heard yelling coming from Resident #78's room and she walked in on the resident's family member pulling and twisting the resident's right arm. When Resident #78's family member was questioned, he stated, She told me her arm hurt and I told her to put it down so I could rub it where it hurt. As Resident #78's family member was doing this, the resident was yelling at him, get off me, let go, someone help me. The nurse intervened immediately and instructed the family member to take his hands off her, and was asked to leave the building. The nurse took the resident to the lobby per her request and the resident stated to the nurse that he was choking her. The nurse then noticed a light-yellow bruise on her left cheek. The resident states, He hit me and that is what the bruise was from. The nurse ensured the resident's safety and notified the DON and Social Services. Resident #78 wanted to file a report and the police were called to come and take a statement. The report stated Resident #78 was very confused about the whole incident with her story changing on how the bruise occurred. It revealed the bruise was first noticed by staff on this day and that the medical director was notified of the incident and discussed the bruise development on the resident's left cheek. It revealed the resident was dependent on staff for all transfers and used a Hoyer lift. Interviews with staff were conducted and reported the resident grabs and moves the Hoyer bars during transfers when educated to cross her arms. As a result of the investigation it identified that all visitation from Resident #78's family member was to be in a public area and upon the resident's approval. Review of the police department incident report dated 07/04/17 revealed on 07/04/17 they were dispatched in reference to a domestic type incident witnessed by a nurse. Upon arrival, the officer met with Resident #78, LPN #305 who witnessed the incident, and the Social Worker. The nurse stated that she overheard arguing or louder talking from Resident #78's room. She then went into the room and observed Resident #78's family member with his hands around the resident's right arm. It indicated that Resident #78 suffers from both physical and mental handicaps. It revealed the officer spoke with the resident and she seemed very confused about the whole incident; at first stated that her family member punched her in the face and leg. It revealed the resident did have an old bruise mark on her face that appeared to be days old. Later the resident stated that the family member had done this in the last week but later again stated she did not know how she got the bruise. The report revealed the social worker and the nurse both confirmed the resident was very confused at times and had mental issues. The report indicated the officer met privately in the hallway with the social worker and the nurse, and a short time later the officer contacted the resident again and asked her what happened during the incident and the resident stated that her family member was spending all their money at the boats. The resident proceeded to say that she got mad and attempted to strike her family member, and then her family member grabbed her by the arm and then the nurse came in. It indicated the Social Worker stated that they would be requiring Resident #78's family member to make visits with the resident in the lobby only and no longer in her room unsupervised. Review of the mental health counseling notes dated 07/06/17 from 9:00 A.M. until 9:20 A.M. identified Resident #78 as tearful and briefly processed the recent event with FM #99. Resident #78 also reported FM #99 pulled her hair because she was not speaking loud enough. Review of the weekly skin assessment dated [DATE] identified Resident #78 was noted with a fading purple bruise to the left cheek. Further review of the medical record failed to indicate this bruise was investigated. Review of the physician note dated 07/14/17 at 4:47 P.M. revealed Resident #78 had a facial bruise and it was unclear of the etiology and had since resolved. Interview with the LNHA and the DON on 08/01/17 at 3:47 P.M. verified the incident that occurred on 07/01/17 between Resident #78 and FM #99 was not investigated. The interview revealed the facility did not consider it abuse as the family member was just showing the nurse how Resident #78 could talk better and that FM #99 was trying to show LPN #300 the resident was able to talk louder, by holding the hole of her [MEDICAL CONDITION]. The DON verified the resident's scared reaction when FM #99 was pressing on her neck, made the nurse question Resident #78 if what he was doing hurt. Knowing their past domestic violence history. The LNHA revealed she didn't feel Resident #78's family member was intentionally trying to harm her. The DON verified Resident #78 was brought to the facility due to abuse at home. Further interview with the DON on 08/01/17 at 4:02 P.M. verified she did not talk to the resident or her family member regarding the incident on 07/01/17 and that LPN #300 did notify her of the situation that occurred. Interview with LPN #300 on 08/01/17 at 7:15 P.M. revealed on 07/01/17 she was in Resident #78's room, finishing up with her G- tube. LPN #300 stated the resident's family member was visiting and lying in her bed, which he usually does when he visits. LPN #300 voiced the resident said something to her and she asked the resident to repeat it, as she could not hear what she said. LPN #300 revealed FM #99 reached around the resident's neck and pushed on the front of her throat four times. She revealed that each time the resident asked him to stop, getting louder each time and by the fourth time she yelled stop. LPN #300 voiced she stepped in and told him to stop and he voiced he was not trying to hurt her, but this was what he did at home to make her talk louder. LPN #300 reported she asked the resident if that hurt her and the resident stated it did hurt. LPN #300 revealed Resident #78 then asked her to take her to the dining room, which she did. LPN #300 stated she called the DON and Social Worker #700 to report the incident and the DON instructed her to document the incident. LPN #300 verified she was concerned for the resident's safety as she thought he was being abusive and she knew there was a history of domestic violence. Interview with Social Worker (SW) #700 on 08/02/17 at 9:00 A.M. revealed that on 07/01/17 she was on vacation and LPN #300 called and informed her of the incident that occurred between Resident #78 and FM #99. SW #700 verified she did not come into the facility to talk to the resident or the resident's family member to follow up on the incident that occurred on 07/01/17. Continued interview with SW #700 revealed on 07/04/17 she was still on vacation and she was again called regarding Resident #78's family member twisting Resident #78's arm. However, she verbalized that she did come in and met with the police officer and Resident #78. SW #700 verbalized that Resident #78 told the police officer that her family member and she were arguing, she hit her family member and then he grabbed her arm. SW #700 voiced they recommended if FM #99 wanted to visit he had to call first, and if Resident #78 wanted him to visit, they would have to be in the lobby. When SW #700 was asked who was supervising the visitor with Resident #78 and her family member, she responded the STNA, a nurse, or someone from the office. Interview with the DON on 08/02/17 at 9:16 A.M. revealed the facility felt the bruise Resident #78 was observed to have on 07/04/17 was in the same area as the one on 07/09/17. The DON voiced that she had spoken with the physician on 07/05/17 regarding Resident #78's bruise to the left cheek. She voiced she asked him how it could be yellow and he voiced if the bleeding was internal then it would show up with a yellow bruise externally. Interview with the LNHA and DON on 08/02/17 at 9:21 A.M. verified the DON notified the LNHA of the incident that occurred on 07/01/17. The DON verbalized that when LPN #300 notified her of the incident she instructed the nurse to explain to her what she felt about the situation and the nurse explained what happened and then asked if the nurse felt the resident was in any harm. The DON voiced that with them knowing the resident and her family member, and knowing the history, that she didn't feel that this incident was intentional. The DON voiced that LPN #300 asked the resident if she wanted her family member to go to the dining room with her on 07/01/17 and resident voiced that was fine, and FM #99 left right after she was finished eating. The DON stated LPN #300 called her because they are told to call and inform them of anything they feel they need notified of. The DON stated on 07/01/17, the resident's family member could visit whenever. Both the LNHA and the DON stated that starting 07/04/17, FM #99 was to call the facility first, and the staff were to ask Resident #78 if she wanted her family to visit; if the resident says yes, then he may visit, but if the resident doesn't want him to visit then he was not allowed to visit. The DON stated that when Resident #78's family member comes and visits, he parks outside of the skilled unit and comes through those entrance doors. She voiced Resident #78 and FM #99 are to sit in the lobby to visit with supervision and supervision was done by an aide, a nurse or one of the office employees. The DON verified there was no place to document when FM #99 visits nor to confirm supervision was completed during these visits. The LNHA stated the staff were educated verbally during shift change regarding FM #99's visits. The DON stated the bruise to the residents left cheek that was present on 07/04/17, was investigated and staff were asked regarding the bruise. She revealed it was identified that the resident uses the Hoyer lift for transfers with getting in and out of the bed and chair. The DON stated the resident grabs the bars on the Hoyer lift 'fearfully' and that the bar could have hit the resident in the face, due to it has hit her in the face in the past. The DON confirmed that on 07/09/17, Resident #78 had a fading purple bruise that was also present to the left side of her cheek that she was unaware was there. The DON confirmed that the yellow bruise to the left side of Resident #78's cheek was not observed prior to it being yellow on 07/04/17 and confirmed she did not investigate the fading purple bruise to Resident #78's left cheek on 07/09/17 due to they felt the bruise was the same one, however was unsure how the bruise went from yellow to purple. The DON also confirmed there was no care plan regarding visitations with FM #99. Interview with State tested Nurse Aide (STNA) #100 on 08/02/17 at 9:35 A.M. revealed that she worked on the skilled unit. STNA #100 revealed that visitors come through the skilled unit entrance doors. STNA #100 stated there are visiting restrictions for FM #99 and if he comes to visit, they are to ask him to leave and if he resists, then they are to get the nurse. Interview with STNA #101 on 08/02/17 at 9:40 A.M. revealed that visitors come through the skilled unit entrance doors. STNA #101 voiced about a month ago there were visiting restrictions for Resident #78. She revealed that if FM #99 came to visit, that they were to ask him to leave. STNA #101 denied currently having any residents who reside in the facility that have visiting restrictions including Resident #78. Interview with STNA #107 on 08/02/17 at 9:42 A.M. revealed when FM #99 visits Resident #78, the staff have to keep a visual check on them and they have to visit in the lobby. STNA #107 voiced that about a week or two ago Resident #78 had a purple bruise on her cheek and that Resident #78 stated her husband hit her. STNA #107 voiced the resident required a Hoyer lift for transfers and the resident holds on during the transfers. STNA #107 denied Resident #78 ever being hit by the Hoyer lift. Interview with LPN #305 on 08/02/17 at 9:40 A.M. revealed there was a plan in place that Resident #78's family member had to call before he visits and this was put in place after the incident that occurred on 07/04/17. LPN #305 voiced the resident's family member calls the nurse on the hallway and informs them what time he wants to visit and if Resident #78 was okay with the family member visiting, then he was permitted to visit. She stated they are not allowed in her room or anywhere private. LPN #305 verified they do not sit with Resident #78 and FM #99 one on one, that staff just has to be in the area. LPN #305 verified she was the nurse who was working on 07/04/17 when the incident occurred between Resident #78 and FM #99. LPN #305 reported that she heard commotion during noon medication pass, so she went to Resident #78's room and witnessed FM #99 using both hands to pull on Resident #78's arm in a downward motion. She stated the resident was yelling 'help me, help me'. LPN #305 said she asked him to remove his hands, which he did. She then brought the resident up in the front with her because the resident was shook up and she reported she called both the DON and SW #700. Interview with STNA #235 on 08/02/17 at 9:40 A.M. revealed the visiting restrictions with Resident #78 and FM #99 included that the resident's door needed to be open when he was at the facility, and that they have to keep a visual check on him when he was visiting. STNA #235 voiced that no one needed to sit with them during visits. STNA #235 denied Resident #78 ever being hit in the face with the Hoyer lift and had never had any concerns during the Hoyer lift with transfers. Interview with LPN #236 on 08/02/17 at 9:43 A.M. revealed visitors do enter through the doors in the skilled unit. LPN #236 denied any residents having any visiting restrictions and denied currently having any residents who currently have visiting restrictions. Interview with LPN #108 on 08/02/17 at 9:45 A.M. revealed when the incident between Resident #78 and FM #99 first happened, they would sit in the lobby and chart, however, since then it's just been a visual check. LPN #108 voiced that on 07/04/17, the resident was very scared and did not want to be left alone. Interview with STNA #401 and STNA #402 on 08/02/17 at 9:58 A.M. revealed they could verbalize the visitation plan in place. Both STNA #401 and STNA #402 reported Resident #78 was nervous and scared using the Hoyer lift for transfers and that she does hang onto the bars, however, they denied being aware of any incident of the resident being hit in the face with the Hoyer lift bar. STNA #401 voiced she noticed Resident #78 bruise to her left check around 07/04/17, however, was unsure how it occurred. Review of the facility policy titled 'Abuse/Neglect/Misappropriation of Resident Property', (undated), identified abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This policy indicated residents of the long term care facility are protected from any physical, mental, sexual mistreatment, neglect or abuse and must ensure that all alleged violations are reported immediately upon discovery of an alleged violation to their direct supervisor. The allegation will be reported immediately or (as soon as possible, but not more than 24 hours after discovery of the incident) to the Administrator or designee. The Administrator or designee will report all alleged violations immediately (as soon as possible, but not more than 24 hours after discovery of the incident) to the state agency and to all other agencies as required. It indicated the results of all investigations must be reported to the Administrator or designee and to the state agency within five working days of the incident. The facility will take all necessary corrective actions depending on the results of the investigation.